WASHINGTON — Senate Republicans, who for seven years have promised a repeal of the Affordable Care Act, took a major step on Thursday toward that goal, unveiling a bill to make deep cuts in Medicaid and end the law’s mandate that most Americans have health insurance.
The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.
But the measure landed in rough seas ahead of a vote that Senator Mitch McConnell of Kentucky, the majority leader, wants next week. Four conservative senators, Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah and Ron Johnson of Wisconsin, announced that they would oppose it without changes — more than enough to bring it down.
“It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs,” the four wrote in a joint statement.
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Other Republican senators, like Dean Heller of Nevada and Rob Portman of Ohio, expressed their own qualms, as did AARP, the American Hospital Association, the American Cancer Society Cancer Action Network and the Association of American Medical Colleges.
“We are extremely disappointed by the Senate bill released today,” the medical school association wrote. “Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare-bones plans that will be insufficient to properly address their needs.”
Once promised as a top-to-bottom revamp of the health bill passed by the House last month, the Senate bill instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.
But the Senate bill would make subsidies less generous than under current law. It would also lower the annual income limit for receiving subsidies to cover insurance premiums to 350 percent of the poverty level, or about $42,000 for an individual, from 400 percent.
Older people could be disproportionately hurt because they pay more for insurance in general. Both chambers’ bills would allow insurers to charge older people five times as much as younger ones; the limit now is three times.
The Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House bill, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.
It would also repeal most of the tax increases imposed by the Affordable Care Act to help pay for expanded coverage, in effect handing a broad tax cut to the affluent in a measure that would also slice billions of dollars from Medicaid, a program that serves one in five Americans, not only the poor but also almost two-thirds of people in nursing homes. A capital-gains tax cut for the most affluent Americans would be retroactive to the beginning of this year.
The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.
If it passes, President Trump and the Republican Congress will be on the edge of a major overhaul of the American health care system — about one-sixth of the nation’s economy.
The premise of the bill, repeated almost daily in some form by its chief author, Mr. McConnell, is that “Obamacare is collapsing around us, and the American people are desperately searching for relief.”
Mr. Trump shares that view, and passage of the Senate bill would move the president much closer to being able to boast about the adoption of a marquee piece of legislation, a feat he has so far been unable to accomplish.