Senate Republicans trying to end the Affordable Care Act suffered their second procedural defeat in less than 24 hours, underscoring how difficult it will be for the GOP to produce a bill despite their triumph in getting debate started on Tuesday.
The measure from Sen. Rand Paul would have, in two years, repealed the Affordable Care Act's Medicaid expansion and eliminated tax credits that help people purchase individual health insurance. The legislation also would have immediately repealed the individual mandate while continuing the Obamacare requirement that insurers offer coverage to those with pre-existing conditions.
It went down 45 to 55.
Wednesday's defeat comes after the main Republican proposal to replace the ACA was defeated 43-57 on Tuesday night, falling far short of the 60 votes required for passage.
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That proposal, known as the Better Care Reconciliation Act, was introduced by Senate Majority Leader Mitch McConnell, R-KY, immediately after the Senate voted 51-50 on to open debate on replacing Obamacare.
The defeat of both repeal measures appears to limit the scope of the Senate's final legislation to replace the ACA.
McConnell — who needs 50 votes to pass repeal legislation under budget reconciliation rules — is now likely to propose a less-comprehensive or "skinny" repeal bill that eliminates only a few major provisions of the health law.
Doing so would likely limit objections from moderate and conservative Republicans and allow McConnell to pass a Senate repeal measure that would then go to a conference committee of House and Senate Republicans.
“We’ve described (the skinny bill) as a trojan horse,” or a “shell to move the process forward,” said Jacob Leibenluft, senior advisor at the liberal Center on Budget and Policy Priorities, “because as soon as you get to conference, you’re back in this discussion of repeal and replace.”
And if a straight repeal-and-replace bill comes out of the conference negotiations, it would be much harder for Republican moderates to vote against it because “it’s either take it or leave it,” Leibenluft said. “Either that bill passes or those senators (who vote against it) will be held responsible for preserving the Affordable Care Act in the minds of their Republican voters.”
Media reports indicate McConnell’s “skinny” proposal would simply scrap the ACA's individual mandate to purchase insurance, the employer mandate to provide insurance and the ACA tax on medical devices.
Conference members would merge the legislation with the more-comprehensive House-passed American Health Care Act, which the Congressional Budget Office found would leave 23 million Americans without health coverage.
That legislative path appears more likely after the Senate parliamentarian on Tuesday ruled that several provisions of the BCRA don't meet budget reconciliation rules and must have 60 votes to pass.
Those provisions include the so-called "age tax" that would allow insurers to charge older people five times more than younger plan members. The ACA allows them to charge three times more. A provision that allows the sale of association health plans would also require 60 votes for adoption.