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Evan Horowitz | Quick Study

Senate tweaks its health care bill in search of votes

The latest bill includes a number of changes, including an amendment pushed by Senator Ted Cruz.
The latest bill includes a number of changes, including an amendment pushed by Senator Ted Cruz.Pablo Martinez Monsivais/Associated Press

Senate leaders released their latest version of health care reform on Thursday, a modestly redesigned bill which they hope will win over wavering senators and fulfill their vaunted promise to repeal and replace the Affordable Care Act, better known as Obamacare.

Perhaps the most controversial change involves an amendment pushed by conservative Senator Ted Cruz. That proposal would allow insurers to offer plans that charge more for people with pre-existing conditions, and insurance companies have already labeled it as “unworkable.”

The latest bill includes a number of changes designed to attract support from wavering members. Among them:

■  An additional $45 billion over 10 years to address the opioid epidemic. That will surely be welcomed by senators from hard-hit states, but it is offset by mental health and addiction services lost to Medicaid cuts.

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■  Another $70 billion that states can use to address problems in their local insurance markets, say by helping insurers deal with unexpected costs. This isn’t a lot of money, but could prove valuable.

■  An option to let people use health savings accounts for pay for insurance premiums, rather than just out-of-pocket expenses. In general, these savings accounts tend to be most useful for wealthy Americans.

All these changes, and others, are paid for by eliminating several tax cuts from the original bill, which makes this version less of a tax windfall for high-income Americans.

Stepping back, though, the real question for the days ahead is: will these changes suffice? Can such tweaks overcome hesitancy among lawmakers, opposition from many health care lobbying groups, and polls showing that less than 20 percent of Americans approved of the Senate’s first effort?

One reason for skepticism is that the changes introduced Thursday don’t really reach to the core of the Republican approach.

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Medicaid will still be cut by nearly $800 billion over 10 years, leaving roughly 15 million Americans without health insurance by 2026 — and millions more in the decade after.

Also, it’s still the case that many people buying individual insurance on the Obamacare exchanges will get less government help and have higher out-of-pocket expenses. Meanwhile, loosened regulations could mean limited or no coverage for areas such as mental health, prescription drugs, or maternity care.

Not to mention the defunding of Planned Parenthood — which at any other time would be heated battle of its own.

Add to this the unpredictable impact of Cruz’s amendment, and the bill’s prospects get even cloudier.

At first blush, the idea sounds perfectly reasonable: Why not let insurers sell different plans to different people? Some of us may want comprehensive coverage, while others prefer plans which are tailored to our health needs and priced according to our individual risks.

With insurance, however, this approach goes haywire pretty quickly.

The trouble is that sick people — and those with pre-existing conditions — are much more likely to sign up for comprehensive coverage, while healthier people tend to choose the skimpier options. And once insurers notice that their comprehensive plans are crowded with sick people, they raise the price, which makes healthier folks drop out — which raises the price even further. Ultimately, you end up in a situation where people with pre-existing conditions or high health expenses needs face unaffordable costs.

Health insurance lobbyists have been warning that this could cause widespread instability in the insurance markets. And Senate leaders have acknowledged they may ultimately have to strip Cruz’s amendment out.

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So what does all this mean for the prospects of the Senate bill?

Senate leaders seem committed to a vote next week. They do have to wait for an updated analysis from the Congressional Budget Office, which could cause additional problems — depending on what the agency finds, and whether it matches Republican talking points.

But before you write anything off, it’s worth remembering that this same strategy worked in the House of Representatives. After their initial bill failed to attract sufficient support, small amendments and little pots of money won over enough skeptics to clear the way for a Rose Garden celebration.

It wouldn’t take much to mount a repeat performance — just a handful of waffling senators who determine it’s better to support this bill than to break their pledge to repeal Obamacare.


Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the U.S. He can be reached at evan.horowitz@globe.com. Follow him on Twitter @GlobeHorowitz