The Senate bill would still make fundamental changes to Medicaid, which covers poor and disabled Americans, including two-thirds of all nursing-home residents. And it would still ask middle-income Americans to pay a larger share of their incomes for health plans with higher deductibles. Moderate Republicans had asked for changes that would make the bill more generous to poor and elderly Americans who would lose out, and those requests were largely ignored.
But the bill eliminates big cuts in payroll taxes and investment taxes for the wealthy, blunting one of the most resonant Democratic lines of attack against the effort. Still on the winners ledger: tanning salons, medical device manufacturers, pharmaceutical companies and health insurers, which all still would get a tax cut.
The revision with the biggest implications for consumers is the Cruz amendment. Two of the biggest insurance industry groups, which have been largely silent as the health debate has played out, spoke out Wednesday in opposition to the amendment. America’s Health Insurance Plans and the Blue Cross Blue Shield Association indicated that they did not wish to operate in the regulatory landscape created by the bill, which they said would split the insurance market in two.
Sicker patients would be likely to flock to more comprehensive coverage, driving up prices, while healthier patients would be more likely to choose stripped-down plans with fewer benefits and financial protections. Those slimmer plans could be a good deal for some Americans in good health, particularly upper-middle-class professionals, whose premiums have risen under the Affordable Care Act.
But those customers could be at a disadvantage once they become sick, since the rules-free plans could be canceled at the end of the year, and premiums would be likely to rise sharply for the heftier plans that would take all comers.
(Mr. Lee, in a statement, said he was still unsure if he would vote for the bill, because he disagrees with some of the fine print in the wording of the provision.)
Actuaries were puzzling over the details Thursday afternoon. “How could this work? I don’t see how,” said Cori Uccello, senior health fellow at the American Academy of Actuaries.
Mr. McConnell’s decision to include Mr. Cruz’s idea mirrors the choice by House Speaker Paul Ryan, who added a deregulatory amendment to the House’s version of the health care bill to help it pass. But the two solutions, each designed to make insurance less expensive for the young and well, are different. The House bill would have asked states to fund special high-risk pools for customers shut out of a broadly deregulated market.
The Senate bill would establish open-ended federal funding for middle-income consumers in that market, by allowing them to use income-based tax credits to help them buy the heftier health plans. People earning more than about $42,000 a year, however, would face sharp premium increases. The bill also sets aside an additional $70 billion over a decade for the federal government to pay directly to insurers that offer plans in that market.
Mr. McConnell held firm against the principal request of Senate moderates: He did not give them substantially more money for state Medicaid programs. Since its creation in 1965, Medicaid has operated as an open-ended partnership between the federal government and the states, with each paying a share of beneficiaries’ medical bills.
The new bill would limit federal spending on the program, shifting an increasing share of its cost to states over time. It would also cut back new funding, established under the Affordable Care Act, to help states insure more poor adults. The nonpartisan Congressional Budget Office estimated that the changes would result in 15 million fewer poor Americans with coverage through the program by 2026.
But even with those cuts, the bill still spends a lot, in assorted inducements for votes. It adds $45 billion in funding for opioid addiction treatment and research, a response to concerns from moderate Republicans, particularly Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who are worried that the drug overdose epidemic would be worsened by the bill’s cuts to Medicaid.
It includes exceptions to the spending caps for declared public health emergencies, a request from Senator Marco Rubio of Florida. His state has been hard hit by the mosquito-borne Zika virus, which causes birth defects. The bill changes a Medicaid formula in a way that benefits states that expanded Medicaid recently: Louisiana, Montana and Alaska, although the Alaska senator Lisa Murkowski has withheld support for the bill. It increases federal Medicaid spending on care for Native Americans, a change that would help states with large native populations, including Arizona, Alaska and North Dakota.
The bill sets aside extra money to help insurance markets with very high health care costs. That provision would benefit only Alaska, handing the state hundreds of millions of dollars in federal funding.
Whether moderates will be satisfied with these smaller sweeteners is unclear. Rand Paul of Kentucky has said he won’t vote for the bill, criticizing it from the right. Among more moderate Republicans, so far only Susan Collins of Maine has said she would block the bill if asked to vote on it in its current form. Mr. McConnell can spare only two defections if he hopes to pass the bill.