Like an M. Night Shyamalan film, the truth of the Senate health bill will only be revealed in the final minutes. After weeks of closed-door meetings, the bill is now being drafted in secrecy by Senate Majority Leader Mitch McConnell and his staff with consultation from some members. Even several Republican senators have not seen it yet.
McConnell plans to release a draft of the bill this week, the full bill next week, then hold a vote within days. With no real details yet in sight, here are some of the big questions still remaining about what will be in the Senate health care bill:
1) What will happen to people with pre-existing conditions?
The American Health Care Act passed by the House would let insurers jack up prices on people with chronic health problems. It does this by letting states choose whether or not to do away with the Obamacare rule that sick people and healthy people must be charged the same rates. The Congressional Budget Office projected this would lead to “extremely high premiums” for people with pre-existing health conditions.
Senators have insisted their bill will be substantially different than the AHCA. But will it still let states waive the pre-existing condition rule? So far, the signs point to yes. Several Republicans have expressed strong support for letting states waive many Obamacare rules. Senate Republicans promise that their bill will take care of people with pre-existing conditions, but it’s not clear how. One option they discussed is using a reinsurance program — essentially having the federal government subsidize insurance companies to help pay for high-cost patients.
2) What will happen to Medicaid and the people who rely on it?
Medicaid is the largest insurer in the country, covering over 70 million low-income Americans, disabled people and children. Former President Obama’s Affordable Care Act loosened the eligibility rules and expanded the health insurance program to 4 million new people.
Republicans plan to both repeal the Medicaid expansion over time and to cap future Medicaid payments to the states. Instead of Medicaid being a program available to anyone who meets the criteria, states would get a set amount of funding and have to craft their systems to work with the funding they have.
The House bill would have cut a projected $830 billion from Medicaid over a decade, according to the CBO, the bulk of which would be put towards repealing Obamacare taxes and lowering the tax burden on the rich. There is little question the Senate bill will do the same, but it may do it over a slower timetable. Whereas the House made its changes in three years, the Senate was looking at more like seven. The Senate could also change how the caps are calculated, resulting in plus or minus billions in funding.
3) What will happen to Planned Parenthood and other abortion providers?
The House bill would have stripped all federal funding from Planned Parenthood. But beyond that, the AHCA found a new way to restrict abortion access. The bill replaced Obamacare subsidies with a system of tax credits to help people pay for insurance premiums. However, these credits could not be used to pay for any insurance plan that covers abortion services.
These issues became a major point of contention in the Senate, where senators like Susan Collins of Maine and Lisa Murkowski of Alaska objected to cutting Planned Parenthood funding. It would also cause problems in California, which requires insurance plans to cover abortions. How can you reconcile a state law that says you have to cover abortions and a federal program that says you can’t receive any funding if you cover abortions?
Many Republicans are insistent on targeting abortion providers in the bill. The big question is which wing of the party will win out.
4) How will senators deal with the opioid crisis?
Republicans are attempting to repeal the Affordable Care Act at a time that the nation is gripped with an opioid epidemic that killed around 60,000 people last year alone. Repeal raises the risk of worsening the epidemic for a couple of reasons.
Before Obamacare, many insurance plans did not offer addiction or mental health treatment. The Affordable Care Act mandated that those services must be covered. Also, almost 30% of the new people who gained coverage through the Medicaid expansion battled a mental health issue or addiction, according to the Substance Abuse and Mental Health Services Administration. Research by Richard Frank of Harvard Medical School and Sherry Glied of New York University suggest that 2.8 million people with substance use disorders, including 222,000 people battling opioid use disorders, would lose some or all of their insurance coverage if the Affordable Care Act is repealed.
Republicans insist their bill will contain measures to combat the opioid epidemic, but the question is whether it will go as far as Obamacare. This puts particular pressure on senators like Shelley Moore Capito, whose state of West Virginia has the highest rate of opioid overdose deaths in the country.
5) How many people will be uninsured, and how many uninsured people are Republicans even aiming for?
There’s little question that the Republican health plan will lead to a rise in the number of uninsured people. The AHCA passed by the House would have led to 23 million more uninsured people over a decade compared to Obamacare, according to the CBO projection. Republicans accept this and have a ready defense — of course insured rates will go down when you stop forcing people to buy insurance they don’t want.
Asked about what their target is Tuesday, South Dakota Sen. John Thune, a member of GOP leadership, switched gears to say their target is making premium rates affordable.
But there may be a way to insure more people for cheap. The idea, pushed by Louisiana Sen. Bill Cassidy, is called auto-enrollment. Essentially, Republicans would direct federal health subsidies to pay for cheap, automatic plans for the uninsured. This could dramatically increase the number of insured people, without individuals even having to act on their own.
There are two major catches. First, these plans would be extremely bare bones and likely only provide coverage for certain catastrophic conditions. Second, it’s entirely possible the plan will run afoul of Senate rules for the special process Republicans are using to avoid the need for Democratic votes (called “reconciliation”) because it is too expensive.
6) Will Americans have time to digest the bill before it is passed?
All of McConnell’s procedural tactics so far have laid the groundwork for extremely swift passage of the Senate health bill. While a draft of the bill is expected Thursday, the full and final text will likely be released just a day or two before the vote. Even some Republicans are grumbling that the bill was written in secret and will not go before any Senate committees to study. But so far none have said they will vote against the bill because they object to the process.
McConnell was questioned by Minority Leader Chuck Schumer Monday about how much time the Senate will get to consider and debate the bill. McConnell said only there would be “ample opportunity” to read the bill. Exactly what “ample opportunity” means remains to be seen.