WASHINGTON — Senate Republicans, who have promised a repeal of the Affordable Care Act for seven years, took a major step on Thursday toward that goal, unveiling a bill to make deep cuts in Medicaid and end the law’s mandate that most Americans have health insurance.
The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, such as maternity care, emergency service, and mental health treatment.
But the measure landed in rough seas ahead of a vote that Senator Mitch McConnell of Kentucky, the majority leader, wants next week. Four conservative senators, Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah, and Ron Johnson of Wisconsin, announced that they would oppose it without changes — more than enough to bring it down.
“It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs,” the four wrote in a joint statement.
More moderate Republican senators, such as Dean Heller of Nevada, expressed their own qualms, as did the American Hospital Association, the American Cancer Society Cancer Action Network, and the Association of American Medical Colleges.
“We are extremely disappointed by the Senate bill released today,” the medical colleges association wrote. “Despite promises to the contrary, it will leave millions of people without health coverage and others with only bare bones plans that will be insufficient to properly address their needs.”
Once promised as a top-to-bottom revamp of the health bill passed by the House last month, the Senate version instead maintains its structure, with modest adjustments. The Senate bill is, in some respects, more moderate than the House counterpart, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.
But the Senate bill would make subsidies less generous than under current law. It would lower the income limit for receiving subsidies to cover insurance premiums to 350 percent of the poverty level, or about $42,000 for an individual, from 400 percent.
Older people could be disproportionately hurt because they pay more for insurance in general. Both chambers’ bills would allow insurers to charge older people five times as much as younger ones; the limit now is three times.
The Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.
It would also repeal most of the tax increases imposed by the Affordable Care Act — a capital gains tax cut for the affluent would be retroactive for this year — to pay for expanded coverage, in effect handing a broad tax cut to the affluent in a measure that would also slice billions of dollars from Medicaid, a health care program that serves 1 in 5 Americans, not only the poor but almost two-thirds of people in nursing homes. The bill, drafted in secret, is likely to come to the Senate floor next week and could come to a vote after 20 hours of debate.
If it passes, President Trump and the Republican Congress would be on the edge of a major overhaul of the American health care system — about one-sixth of the nation’s economy.
The premise of the bill, repeated almost daily in some form or other by its chief author, McConnell, is that “Obamacare is collapsing around us, and the American people are desperately searching for relief.”
Trump shares that view, and the Senate bill, if adopted, would move the president a great distance closer to being able to boast about final passage of a marquee piece of legislation, a feat he has so far been unable to accomplish.
Democrats and some insurers blame the Republicans and Trump for sabotaging the law, in part by threatening to withhold subsidies used to help pay for deductibles and co-payments for millions of poor people covered by the law.
Former president Obama, who has been hesitant to speak up on political issues since leaving office, waded forcefully into the health care debate Thursday, saying the Senate proposal showed a “fundamental meanness” that would harm anyone who gets old, gets sick, or starts a family.
“The Senate bill, unveiled today, is not a health care bill,” Obama wrote on his Facebook page. “It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else.”
In a message to his supporters, the former president urged people to demand real compromise from their lawmakers before senators vote on the bill.
The office of Massachusetts’ governor, Charlie Baker, a Republican, also criticized the bill.
“The administration is concerned that upon a first review, this version falls short and will result in significant funding losses for our state,” the governor’s spokeswoman, Lizzy Guyton, said in a statement. “Governor Baker will keep working with other governors, the congressional delegation, and federal officials to advocate for solutions that work for Massachusetts, including protecting our waiver to support behavioral health and fighting the opioid epidemic and funding for Planned Parenthood.”
Medicaid, known in Massachusetts as MassHealth, covers about 1.9 million state residents.
In the US Senate, Democrats are determined to defend a law that has provided coverage to 20 million people and is a pillar of Obama’s legacy. The debate over the repeal bill is shaping up as a titanic political clash, which could have major implications for both parties, affecting their electoral prospects for years to come.
McConnell faces a great challenge in amassing the votes to win Senate approval. Republicans are trying to pass it using special budget rules that will allow them to avoid a Democratic filibuster. But with only 52 seats, McConnell can afford to lose only two Republicans, with Vice President Mike Pence breaking the tie.
Democrats have already assailed Republicans for putting the bill together without a single public hearing or bill-drafting session.
Priyanka Dayal McCluskey of the Globe staff contributed to this report.