Legislation unveiled by Senate Republican leaders to dismantle President Barack Obama's health care law ran into swift internal opposition Thursday, throwing into doubt the GOP's ability to make good on a years-long campaign promise to roll back the program.
Hours after the bill was made public, four conservative senators announced their opposition, saying the measure doesn't go far enough to unwind Obamacare. Maryland Gov. Larry Hogan, meanwhile, joined a chorus of centrist Republicans who are concerned about how the legislation would affect their states.
Hogan, a popular governor up for re-election next year, does not have direct influence over what is playing out in Washington and has largely avoided weighing in on national politics. But his position will almost certainly be used by opponents of the law to pressure Republican senators who are on the fence.
"We know the current system needs to be fixed, but the proposals that are being considered in Congress do not work for Maryland," Hogan spokeswoman Amelia Chasse said in a statement — the strongest the governor's office has issued on the issue.
"Congress should go back to the drawing board in an open, transparent and bipartisan fashion to craft a bill that works for all Americans," she said.
Drafted behind closed doors, without hearings or input from many Republicans — let alone Democrats — the Senate measure calls for deeper cuts to the Medicaid program for low-income Americans than a bill approved in May by the House that President Donald J. Trump described as "mean."
The legislation would leave millions more Americans uninsured, but Republican leaders hope it would stabilize insurance markets. It would direct $50 billion over four years to help states experiencing rising premiums in private insurance, and it would only slightly alter subsidies that help families buy insurance through Obamacare exchanges.
Senate Majority Leader Mitch McConnell of Kentucky, who crafted the proposal, laid out the Republican argument Thursday in stark terms: Obamacare, as it stands now, is unsustainable, he said.
"Obamacare isn't working. Republicans believe we have a responsibility to act, and we are," McConnell said.
The effort to repeal Obama's signature domestic policy achievement has appeared dead before, only to build momentum and move to the foreground of the agenda. Opposition from conservative and centrist Republicans ended earlier efforts in the GOP-led House, but that chamber narrowly approved a similar bill after making only modest changes.
McConnell, a skilled negotiator, described the legislation as a "discussion draft" and pressed the chamber to vote on it as early as next week. But it appeared the bill would need substantial changes before a vote, and negotiations will likely run into the same tension between conservatives and centrists that vexed House Speaker Paul Ryan.
"We want the bill to look more like a repeal," said Sen. Rand Paul of Kentucky, an ophthalmologist elected to the Senate in 2010 at the height of the political furor over the Affordable Care Act.
Paul was joined in that assessment by Republican Sens. Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah. In a statement, the senators said that they were "not ready to vote for this bill" but that "we are open to negotiation."
The challenge is that provisions designed to appease conservatives like Paul could cost support from centrists, who are concerned about the impact of cuts to Medicaid. There is little margin for error in the Senate, where Republican leaders can lose only two Republican votes if they want to pass the bill.
Trump, who campaigned on repealing Obamacare and celebrated the passage of the legislation in the House, appeared to offer only tepid support for the Senate bill. Speaking at an unrelated event at the White House, the president twice noted that negotiations are still ongoing.
"We will hopefully get something done, and it will be something with heart and very meaningful," he said. "We'd love to have some Democrat support, but they're obstructionists."
He later posted on Twitter that he was "very supportive."
Democrats pounced not only on the legislation, but also on the way it was crafted — without hearings.
"This 'solution' is nothing more than trying to repeal an Obama legacy and not looking at the health care policy that is critically important to the American people," said Democratic Sen. Ben Cardin of Maryland.
The bill eliminates the requirement that Americans buy coverage or face a tax penalty — the so-called individual mandate — but it requires insurers to cover anyone who applies, even if they have pre-existing conditions. While that structure eliminates one unpopular provision of Obamacare and keeps a well-liked protection, it creates an incentive for people to wait until they become sick to buy health coverage.
Republican aides said Thursday they still are studying language approved by the House that would let insurers charge more if a buyer allowed prior coverage to lapse.
At the center of both the House and Senate bills are deep reductions in federal aid for low-income Americans enrolled in Medicaid. The Senate would cap federal funding to states for Medicaid at an even sharper rate over time, forcing them to find some other way to fund the program or to reduce coverage.
The 52-year-old Medicaid program serves some 75 million beneficiaries nationwide, including 1.3 million in Maryland.
The Senate bill also would phase out a Medicaid expansion created under Obamacare. To date, 31 states — including Maryland — have expanded Medicaid under that program, helping to significantly reduce the number of uninsured. More than 274,000 Marylanders have enrolled in that program.
Those numbers likely explain Hogan's reaction. Aides have said previously the governor has met with members of the Trump administration about proposed Medicaid cuts.
Dr. John B. Chessare, president and CEO of Greater Baltimore Medical Center, said hospitals in the state could suffer under the proposed legislation. Hospitals like his could easily lose ground gained under the Affordable Care Act, which he said has helped patients manage chronic conditions and stay out of emergency rooms.
"That the richest country in the world would try to fix a problem by going after the most unfortunate is really kind of sad," he said.
Hospitals, Chessare said, likely would end up treating more patients without insurance, which would raise their uncompensated care costs.
In a statement, Dr. Leana Wen, the Baltimore City Health Commissioner, said "the bill released today would endanger the lives of the most vulnerable members of our community."
She cited the Medicaid cutbacks, increased costs for older people and the ability for state's to waive required coverages.
"The Senate's proposal will hurt — not help — the health of Americans," Wen said. "I urge our nation's leaders to consider and act in the best interest of the well-being of our fellow community members."
The Senate legislation was unveiled as insurers are raising premiums or pulling out of the insurance markets created by Obamacare, squeezing those enrolled in private plans. In Maryland, state officials began this week considering significant rate increase requests from several companies selling coverage in the market.
Those increases appear to be spurred in part by the provisions of Obamacare, but also by uncertainty in the market caused by the Trump administration. The White House has signaled, for instance, that it might no longer enforce the individual mandate — which could prompt healthier people to leave the insurance market and drive up prices for those who remain.
Asked about the statement from the governor's office, Rep. Andy Harris said Hogan is viewing things from the state's perspective but that Congress needs to look at the issue through the prism of the federal government.
"We're running a $20 trillion debt and a $500 billion deficit," said the Baltimore County Republican and anesthesiologist, who supported the House version of the health care bill. "We had to control the uncontrolled growth in the Medicaid program, and the Senate bill does that."
The day's events put Harris in the position of not only being publicly out of step with his state's governor, but also supporting a measure that other Republicans said does not meet the promise of repealing Obamacare. Harris, a member of the House Freedom Caucus, has hewed closely to the conservative wing of the party.