US Senator Shelley Moore Capito, a Republican, has voted more than 50 times in Congress to repeal the Affordable Care Act (ACA). She plans to do it again this spring, but talking with voters in her impoverished state, which has a high rate of drug addiction, obesity and poor health, has given Capito a new sense of caution.
“I met a woman the other day with a terrible illness,” she said. “She is really sick and really scared.”
Capito and other Republican lawmakers, particularly in the Senate, increasingly see a need to tread carefully, or even alter course, as party leaders vow to quickly repeal and replace the healthcare law. That unease is all but certain to have an enormous effect as House and Senate Republicans begin to publicly draft a plan this month.
Animated by full control in Washington, Republicans have chosen a partisan route to remaking the law, in which 218 votes in the House and a mere 50 in the Senate are needed to repeal and replace it.
While much of the focus has been on the potential for hardline conservatives to act as spoilers with their opposition to anything but a bare-bones replacement, there is increased wariness among Republican senators who have the opposite concerns.
“Once low-income people are receiving good healthcare for the first time, it becomes very difficult for a member of Congress to take that assistance away from them,” said Senator Susan Collins, a Republican. “To deprive them of that healthcare is something that now makes a lot of people in my party uncomfortable.”
She has cosponsored a replacement plan that would let states keep many of the law’s components now under fire from House of Representatives Republicans.
US President Donald Trump has heightened the stakes, at times insisting that lawmakers replace the law immediately while repeatedly saying that no one should lose insurance coverage under a replacement plan. Patients with chronic illnesses, drug addicts, rural hospital executives and expectant mothers — many of whom voted for Trump — have made it clear that they will not support any plan that deprives them of what they have, even if they dislike its origins in former US president Barack Obama’s administration.
“Voters may not know how they got their healthcare, but they sure will know who took it away,” Senator Joe Manchin III said, who has long endorsed making changes to the law.
Republicans hope to send a new healthcare measure to the president’s desk this spring, but vast chasms have been exposed between the most conservative members and other Republicans, and the White House has yet to provide clear guidance by endorsing specific provisions.
While promising to maintain the most attractive parts of the law, like forcing insurers to offer coverage for patients with pre-existing conditions, congressional Republicans have long set a central goal of ensuring “access” to care — not guaranteeing care — while shoring up the insurance marketplace.
However, Trump upended that message when he said in January that any Republican plan would “have insurance for everybody,” a notion he has repeated.
Lawmakers have taken notice, sometimes echoing his language.
“I think the no-gaps-in-coverage part is important,” Capito said, adding that expanded coverage was the Obama administration’s main focus. “For every push, there is a pull.”
Trump has further complicated matters by insisting that any plan replace the law as soon as it is repealed; Republicans had hoped to put the replacement off.
In addition, the Affordable Care Act’s Medicaid expansion — which has extended coverage to roughly half of the 20 million people who have gained insurance under the law — has been embraced by a majority of governors. Many of them, including Republicans, have said in meetings with both lawmakers and Trump that they want to continue that program.
“While I clearly have concerns about the expansion’s long-term costs, it has strengthened our Native health system and reduced the number of uninsured that are coming into our emergency rooms,” Senator Lisa Murkowski said in an address to the Alaskan legislature last month.
“So as long as this legislature wants to keep the expansion, Alaska should have the option. So I will not vote to repeal it,” she said.
Even senators in states with no Medicaid expansion concede that the law is baked into the culture, sometimes in ways their constituents are not fully aware of, and in ways they themselves have fought for. Most notably, the Affordable Care Act has increased money and access to programs for Americans with mental illness and drug addiction, especially in states like Ohio that accepted the Medicaid expansion and have a large population of opioid drug users.
“While we work to reform Medicaid as part of replacing the ACA,” said Senator Rob Portman, who has made the opioid crisis one of his chief concerns. “Close attention must be paid to the growing opioid epidemic and the need for drug treatment and recovery.”
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