Tierney Sneed

Tierney Sneed is a reporter for Talking Points Memo. She previously worked for U.S. News and World Report. She grew up in Florida and attended Georgetown University.

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Language tucked deep in the Medicaid provisions of the Senate GOP Obamacare repeal legislation appears to allow states to funnel leftover Medicaid money for use on roads, bridges, stadiums and other projects not directly related to Medicaid’s traditional definition.

A GOP aide is already walking back the language, telling the Washington Post on Monday that it was “an inadvertent error” and that the language would be fixed before a final bill is filed for a vote.

Yet health care experts say that language points to the larger problems posed if states take congressional Republicans up on their offer to convert Medicaid’s structure into a lump sum system under the Senate GOP bill.

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The CBO score released Monday on the Senate health care bill rained down what must have been the worst nightmare—or close to it—for the GOP senators squeamish about the bill: blockbuster coverage losses just about as bad as the House version’s, Medicaid provisions that kick off even more people from the program than the House bill and average premium reductions that come at the cost of making insurance inaccessible for many low income people.

Already, it appears Senate Republicans don’t have enough votes to advance the legislation, and it will be a scramble to get that number up to 50 for Senate Republicans to pass the bill, the Better Care Reconciliation Act, this week, as planned.

Lawmakers will only have a day, maybe two, to analyze the report before GOP leaders are expected to move forward with a procedural vote to advance the legislation Tuesday or Wednesday, with the goal of a final vote by the end of the week. Before the score was released, a handful of conservatives and two moderate Republicans had signaled opposition to the draft legislation, though the conservatives said they were mostly open to negotiations. About a half dozen more moderate Republicans, and particularly those from Medicaid expansion states, are in the hot seat to make up their mind about supporting the bill, and the CBO score only turns up the temperature.

Here are 5 points on how Monday’s score affects GOP leaders’ ability to find 50 votes in favor of the legislation:

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Twenty two million fewer people would have insurance under the Senate GOP’s health care bill by 2026 when compared to current law, the Congressional Budget Office said Monday. The CBO’s analysis of the Senate’s Better Care Reconciliation Act, which would partially dismantle the Affordable Care Act, comes just days before the Senate is expected to vote on the bill.

The analysis find that the Senate Republicans did not much better than their House counterparts—whose Obamacare repeal bill the CBO found would result in 23 million losing insurance—in staving off devastating coverage losses under their plans. The CBO said of the Senate bill on Monday that the first round of coverage losses, some 15 million in 2018, would come from the elimination of the individual mandate.

As time goes on, the Senate bill’s deep cuts to Medicaid would take hold, and the CBO predicted that by 2026 enrollment in the program among those under 65 would fall by 16 percent. By 2026, the CBO predicts 15 million fewer people enrolled in Medicaid under the Senate bill compared to current law.

The CBO found that the Senate bill imposes a $772 billion cut on Medicaid and, by making Obamacare’s tax credits less generous, saves the government another $408 billion. Those funding cuts in turn go to pay for the repeal of many ACA taxes (costing the government $541 billion), the loss of the mandates (costing $210 billion) and the funding for states and insurers ($107 billion). The silver lining in Monday’s report for Senate GOP leaders is that their bill altogether reduces the deficit by $321 billion, giving them about $200 billion to play with in order to win the votes of skeptical moderates.

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With just a few days before an anticipated vote, Senate Republicans released a revised version of their Obamacare repeal legislation Monday that adds a continuous coverage requirement to the draft bill they unveiled last week.

The original draft, known as the Better Care Reconciliation Act, repealed the Affordable Care Act’s individual mandate, but did not include a similar mechanism in its place incentivizing healthy people to get insurance. Health care experts and insurers warned that such a system would risk a death spiral, as only sick people sought coverage.

The revised legislation released Monday requires insurers to impose a six-month waiting period on those seeking to join plans if they have had a break in coverage lasting two months or more in the previous year. Vox and other outlets over the weekend reported that Senate Republicans were considering the change to their bill.

Under the Affordable Care Act, people who lose coverage and don’t promptly use a special enrollment period have to wait until the next open enrollment period to regain coverage. The Senate provision adds a six-month waiting period on top of that — the later of either six months after his or her application for insurance or the first day of the next plan year.

The House bill, the American Health Care Act, included its own version of a continuous coverage requirement that imposed a 30 percent surcharge on consumers who had not maintained continuous coverage when they sought to enroll in a plan. The Congressional Budget Office was skeptical of the effectiveness of such a penalty. It remains to be seen how it will assess the Senate’s version, but Obamacare supporters are already criticizing it for locking out consumers from coverage if they have a gap in coverage.

The Senate provision includes an exemption for newborns and those under 18 years of age who are newly adopted.

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The Republican state official tapped by President Trump to lead his sketchy voter fraud commission was sanctioned by a federal judge Friday for his “deceptive conduct and lack of candor” in a voting rights case brought against him.

Kansas Secretary of Kris Kobach will have to pay the court a $1,000 fine as punishment for “patently misleading representations” during the litigation over the proof-of-citizenship voter registration requirement Kobach is seeking to implement in his state.

As part of its lawsuit challenging the requirement, the ACLU asked the court to sanction Kobach for how he handled the group’s request to view documents believed to be proposals to amend the National Voter Registration Act, including a proposal he was photographed holding while meeting with Trump back in December. The ACLU’s legal challenge against his proof-of-citizenship requirement claims it to be in violation of the NVRA, making the documents potentially relevant to the case.

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At first glance, it appeared the Senate Obamacare repeal legislation took a less aggressive approach than House Republicans to the waivers offered to states to opt-out of Affordable Care Act insurer mandates. In fact, some conservatives were griping about it.

But, while substantively the Senate GOP proposed waivers look narrower than the House bill’s version, procedurally they are incredibly more lax. That means states will have all kinds of space to wreak havoc on Obamacare’s consumer protections, even as Senate Republicans claim they’re protecting people with pre-existing conditions.

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Sen. Dean Heller (R-NV) announced Friday that he is opposed to the Obamacare repeal legislation unveiled by Senate GOP leadership this week in its current form and that he won’t vote to advance if it is brought up for a procedural vote early next week.

“In this form, I will not support it,” Heller said. Heller is up for reelection in 2018 and is from a Medicaid expansion state. He cited the rollback of expansion has his reason not to support it.

“This bill…is simply not the answer,” Heller said.

Heller faces perhaps the toughest reelection race next year of all the GOP senators who will be on the ballot, so it’s not entirely surprising he came out against the bill, given how deeply unpopular the House version of the repeal legislation has shown to be. However, it was notable that Heller would condemn the Senate proposal in such strong terms and not just for its Medicaid cuts.

“There isn’t anything in this bill that would lower premiums,” Heller said.

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Senate Republicans, in their recently unveiled bill to dismantle the Affordable Care Act, included cuts to Medicaid funding that are even more cynical than what the House version of the legislation imposed—on both a political and policy level.

To shore up the support of Senate conservatives, who might balk at how the Senate bill softened the phaseout of Medicaid expansion, Majority Leader Mitch McConnell (R-KY) made even more draconian cuts to the traditional Medicaid program in the long-term.

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The conservative complaint that the Affordable Care Act led to higher out-of-pocket costs has been so deeply ingrained into GOP Obamacare repeal talking points that even President Trump—he of “Nobody knew that health care could be so complicated” fame—managed to work it into his tweet storm messaging.

But like other aspects of the health care bill Republican lawmakers are currently pushing, their approach would likely make the problem they raised constantly to bash Obamacare actually worse.

The reasons are wonky but incredibly important, because consumers will likely see their deductibles and co-pays rise if the Senate health care overhaul bill, the so-called Better Care Reconciliation Act, goes into law. And the way the Senate proposal is structured, it also means that the tax credits offered under the GOP bill give consumers get significantly less bang for their buck, even as they largely follow the model of the ACA subsidies.

The key provision is the Senate bill’s proposal to change what is known as the actuarial value of the benchmark plans that the tax credits would be pegged to. Under the current law, the tax credits are formulated according to the second lowest premium rate for a “silver plan” in a given area, and silver plans are required to have a 70 percent actuarial value. That means that that the insurer will pay 70 percent of medical costs a typical consumer incurs, while leaving the consumer to pick up the tab for the rest via deductibles, co-pays or other cost-sharing mechanisms.

The Senate bill lowers this base level to 58 percent actuarial value, which is at the bottom end of what are known as “bronze plans” currently under the ACA. By the math of Kaiser Family Foundation vice president Larry Levitt, the value of the premium subsidies are therefore reduced by around 15 percent.

On the front end, this will make it look like premiums are lower under the GOP plan. But the reduction in actuarial value shifts that burden elsewhere, likely to co-pays and deductibles. Consumers on the older end of the spectrum will be hit especially hard by this change, due to other ways the Senate bill tweaks ACA limits regarding age and how the tax credits are doled out.

This tweak is coupled with a state waiver provision of the bill that will allow states to opt out of the ACA’s limits on cost-sharing.

A 2015 brief by the Urban Institute found that with plans at 60 percent actuarial value—the bottom limit at the time under the ACA—the out-of-pocket costs would shake out to be around $6,850 for single policies and $13,700 for family policies.

Under the ACA, at least those deductibles were defrayed for low-income consumers by insurer subsidies known as cost-sharing reduction payments. But under the Senate Republican plan, the cost sharing reduction payments will be repealed at the end of 2019, and it’s left up to the states to enact programs that could assist low income people with these deductibles.

There is a conservative philosophy that right-leaning health policy wonks will offer in favor of higher cost-sharing. They are argue that if consumers are exposed more directly to health care costs, they’ll be more selective about what services they receive, prompting market forces to drive down the prices.

This rationale was no where to be found when Republican lawmakers pointed to out-pocket-costs to slam Obamacare, even as they intended to push a plan that would only exacerbate that problem.

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Within a few hours of the release of the Senate legislation to dismantle the Affordable Care Act and overhaul Medicaid, four conservatives came out against the bill, putting Majority Leader Mitch McConnell (R-KY) two votes short of what he will need to pass it.

But this is not, by any means, the death knell for the bill, dubbed the Better Care Reconciliation Act, and it might not be even a major obstacle.

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