WASHINGTON — Alaska's Sens. Lisa Murkowski and Dan Sullivan joined their Republican colleagues in the first hours of Thursday to pass a parliamentary measure that is the first step toward dismantling the Affordable Care Act.
There are limits to what Republicans can accomplish with only a simple, 51-person majority in the Senate, but they hope gutting the tax-and-spend provisions of the health-care law will bend Democrats toward compromise and spur major change.
In interviews this week, Murkowski and Sullivan said they hope to quickly remove the law's mandate that citizens and employers purchase insurance, cut federal requirements for what health insurance plans must offer, and peel back the taxes originally designed to pay for it all.
But, for the next two years at least, they also want to make sure subsidies stay in place. They've promised to make sure an Alaska Native and American Indian health law remains intact. They say the focus of replacement legislation for the Affordable Care Act must make health care affordable. And they say the No. 1 thing they hear from Alaskans, and hope to achieve, is cost transparency: People want to know what a procedure will cost before the bill arrives in the mail.
But a lot of questions remain about how they're going to manage all of that.
Murkowski and Sullivan joined Republicans in a 51-48 vote early Thursday on a budget reconciliation, a procedure that will allow them to repeal parts of so-called Obamacare without having to reach the typical 60-vote threshold required to pass most bills in the Senate.
But the scope of the annual budget reconciliation is limited to issues related to debt and spending. That means that quite a few of the law's more popular provisions cannot be repealed without support from Senate Democrats.
During the series of votes Wednesday and Thursday (often referred to as a "vote-a-rama"), Murkowski and Sullivan joined Republicans in voting down Democrats' amendments that supported popular provisions of the health-care law: requiring insurance companies to provide service to people with pre-existing conditions; allowing young adults to stay on their parents' health plans until age 26; and supporting Medicaid expansion.
But those amendments were more about hijacking the process than those individual provisions of the law. The reconciliation vote was not for a law, but to establish a plan for congressional committees going forward.
"Just as the vote on the budget resolution was not a vote to repeal the ACA, the votes on individual amendments were not votes for or against any specific provision but rather about the establishment of the process. Senator Murkowski remains committed to retaining or improving several Affordable Care Act provisions, including the prohibition on discriminating against individuals based upon pre-existing conditions and allowing those 26 or under to remain on their parents' insurance policies. She is also keenly interested in the Medicaid expansion provisions," said Murkowski's spokeswoman Karina Petersen.
Sullivan's spokesman, Mike Anderson, similarly said that the votes don't "reflect the senator's policy views on the necessary elements of an Obamacare replacement."
Murkowski and several other moderate Republicans also dropped their own amendment aimed at drawing out the timeline for repealing the ACA to offer a clearer "replacement" plan at the same time.
Murkowski noted on Wednesday that she had been informed the Jan. 27 target date was not a firm deadline, and questioned what the point was, in that case.
The House is expected to take up the reconciliation bill Friday, and then relevant committees will get to work on crafting "repeal" plans — at least for the tax-and-spend portions of the ACA.
But on the Senate side, the fact remains that major changes will have to come with help from Democrats, unless they can be done through administrative orders issued by President-elect Donald Trump and his secretary of Health and Human Services.
"Reconciliation only allows you to deal with basically the taxing end, the finance end," Murkowski said. "So it's an imperfect process, but it's what we have."
"If anybody thinks that we're going to be able to fix this with just Republicans because we have the White House and we have majorities in the House and the Senate — that defies the reality of how things work in the Congress. We have to have bipartisan support here in the Senate," Murkowski said.
Republicans are limited in what they can do with only 51 votes — it won't involve a full repeal of all ACA issues, only items related to taxing and spending. The mandates (backed by tax penalties for individuals and companies that don't comply) will be out.
Medicaid expansion will likely eventually be gone.
That's something that's been a daily discussion among Republicans, Sullivan said. "We want to make sure this is an orderly process that covers and brings affordable care — real affordable care — with flexibility, to as many Alaskans as possible," Sullivan said.
Both senators said they don't expect the subsidies to be gone soon.
"Look, we're not looking to pull the rug out from people who have relied on this law, even though the law is not working," Sullivan said.
In Alaska, only one insurer — Premera — remains on the exchange, and premiums are some of the highest in the country and rising. Most Alaskans who are using the federal exchange — roughly 80 percent — get subsidies. But as upper-middle-class families edge out of the allowed range of subsidies, deductibles often run upward of $10,000 per year.
But the Affordable Care Act does require that insurance companies offer preventive care outside of those required deductibles — annual checkups designed to keep people on high-deductible plans from missing big health problems before it is too late.
"Look, what I'm trying to do is fix the unbalance. We've lost four or five insurance providers already. We've seen premiums skyrocket. We've seen deductibles become unaffordable. For thousands of Alaskans, so-called coverage is not coverage at all. It's not coverage if you can't afford it," Sullivan said.
Health policy experts said that earlier efforts to repeal the ACA could provide a guide for how the Republicans will go: eliminate the Medicaid expansion, cut subsidies, but not for two or more years, and immediately cut associated taxes and any requirements for individuals and companies to buy insurance.
According to the Urban Institute and the Center on Budget and Policy Priorities, about 62,000 Alaskans would lose coverage with repeal of the ACA. The state would lose $3.2 billion in federal funding, most of that marketplace subsidies and Medicaid funding.
Most Alaskans receive subsidies that cover about 85 percent of their monthly premiums. That means an average-rate premium of $737 would cost $126 a month, according to the Center on Budget and Policy Priorities.
Nobody in the Republican caucus is looking to erase subsidies overnight — at least not in the Senate, Murkowski said. "It has been more of a recognition that if you're going to remove those subsidies … how are you going to address these individuals who will be without? What is that plan?" Murkowski said.
And Murkowski noted that she is "very, very sensitive to the fact that through Medicaid expansion, and through the federal exchange, we have more Alaskans that are covered now that are receiving assistance than have had that opportunity previously."
And "we need to make sure that these people don't get kind of lost in the shuffle here," Murkowski said.
The plan isn't entirely clear yet. But Murkowski and Sullivan do have a list of changes they'd like to see come to fruition soon, some of which they hope will drive down costs. That may emerge as a series of bills.
"The Affordable Care Act was nothing to do with affordable care. It was everything to do with requiring you to have insurance," Murkowski said.
Murkowski's and Sullivan's list of changes includes re-opening the market to lower-quality, high-deductible insurance that offers a lighter monthly payment.
That would come with a series of moves: Both senators said they want to see the list of "essential health benefits" eliminated. "Because right now the federal government tells you what the plans have to look like. Doesn't matter how old you are, you still have to have plans that allow for maternity," Murkowski said. She said eliminating such requirements would cut costs.
Under the ACA, insurance companies are required to cover about a dozen types of health-care costs, including emergency care; lab tests; preventive care, like annual checkups; and maternity care.
The senators said they thought there should be more options for "catastrophic" health care for young, healthy people. That would mean paying a lower monthly charge, but a very high deductible: Health-care costs would essentially be out-of-pocket until something very expensive came up.
And they hope to quickly lift the cap on Health Savings Accounts, which allow people with high-deductible health plans to stow away savings without being subject to income taxes.
But Sullivan said they have made promises to keep some portions of the ACA in place. That includes the Indian Health Care Improvement Act, which, in part, updated the laws for financing at health care centers. It was included in the 2009 passage of the ACA. Murkowski and then-Sen. Mark Begich D-Alaska co-sponsored the bill.
Alaska Native groups were worried the bill would be repealed this year, but "that's not happening," Sullivan said. The reconciliation instructions to committees made clear that "we are not going to touch that, and we've clarified that with everybody," Sullivan said.
The major new option that the lawmakers hope to offer is greater pricing transparency — though that has been largely opposed by hospitals and other caregivers.
"Your pipes break, you call the plumber, you say, 'How much is this going to cost me?' He might not be able to tell you exactly, but he can tell you what he bills by the hour. We don't even get that from our health-care system," Murkowski said.