The Senate blocked a bill Thursday to extend Affordable Care Act health insurance subsidies, all but ensuring they will expire at the end of the year.
The vote was the culmination of Democrats’ months-long push to extend the subsidies and prevent premiums from rising for millions of Americans — a campaign that helped trigger the longest federal government shutdown in history. Republicans promised to hold the vote as part of a deal to end the shutdown.
Four Republicans — Sens. Susan Collins (Maine), Dan Sullivan (Alaska), Josh Hawley (Missouri) and Lisa Murkowski (Alaska) — voted for the Democratic bill, which needed 60 votes to advance. It got 51, with 48 senators voting against.
The Senate also blocked a Republican health care bill that Sens. Bill Cassidy (Louisiana) and Mike Crapo (Idaho) drafted as an alternative to the Democratic one. That bill, which also needed 60 votes to advance, failed 51-48, with Sen. Rand Paul (R-Kentucky) joining every Democrat in voting no.
Senate Minority Leader Charles E. Schumer (D-New York) castigated the Republican bill — which would give many Americans up to $1,500 in tax-free accounts to spend on health care instead of extending the subsidies — as insufficient.
“The Republican bill is little more than junk insurance,” Schumer said Thursday on the Senate floor. “It is no real plan at all.”
Republicans have countered that Democrats’ bill would do nothing to combat Americans fraudulently claiming the subsidies or rein in their growing cost to the federal government. Senate Majority Leader John Thune (R-South Dakota) accused Democrats of being more interested in campaigning on the issue in next year’s midterm elections than in compromising with Republicans.
“Democrats may talk about helping Americans, but their bill is nothing more than a political messaging exercise that they hope they can use against Republicans next November,” Thune said on the Senate floor.
While almost every Republican senator voted for the GOP health care bill, Republicans are far from united on how to rework the ACA eight years after their effort to repeal and replace the law collapsed in dramatic fashion.
House and Senate Republicans in recent weeks have introduced at least nine different health care plans, with more in the works. Two plans backed by House Republicans have bipartisan support, but the Senate plans are partisan.
Some Republicans want to extend the ACA subsidies that Democrats enacted in 2021 before they expire at the end of the year, while others stress they were always temporary and argue they merely paper over the underlying problem of rising health care costs.
“The challenge Republicans have always had is trying to unify behind a single proposal,” Sen. John Cornyn (R-Texas) told reporters. “We’ve just got too many good ideas.”
Republicans also struggled to coalesce around their 2017 health care bill, which the Congressional Budget Office estimated would cause millions of Americans to lose coverage.
It was an easy target for Democratic attacks, and the entire effort ultimately collapsed after Sen. John McCain (R-Arizona) cast the deciding vote against a whittled-down measure on the Senate floor.
Most Republicans currently in the Senate were there for the 2017 fight, but only a handful of staffers who helped draft the House and Senate bills to repeal and replace Obamacare are still on Capitol Hill.
Some Republicans argue that the party has never been comfortable crafting health care policy, because it is deeply entwined with government, which the party traditionally has sought to cut. Republicans tend to focus on reining in Medicare and Medicaid costs — which together consume roughly one-quarter of federal spending — while Democrats have prioritized expanding coverage.
“It’s hard because Republicans aren’t central planners,” said Joe Grogan, director of the White House Domestic Policy Council during Trump’s first term.
The Republican health care plans introduced in recent weeks are much more modest than the 2017 legislation. Instead of seeking to repeal and replace Obamacare, they attempt to rework or replace the expiring subsidies.
“They are tiny by comparison,” said Doug Holtz-Eakin, a former CBO director who is president of American Action Forum, a conservative think tank. “These are rifle-shots of reform, and they’re not going to have a big impact on the larger health care delivery issue.”
Some of the Republican plans would extend the ACA subsidies for one or two years with changes that Republicans argue would help combat fraud in the program. Others — including the one the Senate voted on Thursday — would fund health savings accounts instead.
“The Republican counterproposals are all over the place,” said Cynthia Cox, director of the ACA program at KFF, a health care think tank. “They span a really wide range here that is probably representing how fragmented Republicans are on health insurance issues more broadly.”
A plan from Sens. Bernie Moreno (R-Ohio) and Susan Collins (R-Maine), for instance, is similar to what Democrats and Republicans have discussed as the basis of a bipartisan compromise. A bill from Sen. Rick Scott (R-Florida) “could blow up the ACA marketplace” in some states if enacted, Cox said.
House Speaker Mike Johnson (R-Louisiana) has vowed that House Republicans will come up with their own proposal and vote on it next week before lawmakers leave for the holidays.
“We have some low-hanging fruit, we have some things that every Republican agrees to,” Johnson told reporters Wednesday. “You’re going to see a package come together that will be on the floor next week that will actually reduce premiums for 100 percent of Americans, not just the 7 percent” who receive the ACA subsidies that are set to expire.
The bill will not extend the expiring subsidies, according to House Majority Leader Steve Scalise (R-Louisiana), frustrating a small group of moderate Republicans.
Fourteen Republicans bucked Johnson on Wednesday by signing a discharge petition introduced by Rep. Brian Fitzpatrick (R-Pennsylvania) to force a House vote on a bipartisan bill that would extend the subsidies with some changes. Eight of them also signed a second discharge petition introduced by Rep. Josh Gottheimer (D-New Jersey) to force a vote on a different bipartisan bill to extend the subsidies.
“This is personal to a lot of us. These are our friends and our neighbors that are losing sleep over this,” Fitzpatrick told reporters Wednesday. “So we just have no time, no patience for the BS politics that sometimes consume this place.”
Bipartisanship has been more elusive in the Senate.
When Sen. Jon Husted (R-Ohio) sought unanimous consent Wednesday to pass his bill to extend the subsidies for two years, Sen. Tammy Baldwin (D-Wisconsin) blocked it from passage.
She argued that changes included in the legislation would lead millions more Americans to lose health insurance and would not prevent premiums from rising. She also criticized the bill barring plans bought using the subsidies from covering abortion.
“This bill is a deeply unserious proposal to a very serious problem,” Baldwin said on the Senate floor.
Many Democrats and Republicans view abortion as the biggest hurdle to striking a deal to extend the subsidies.
Republicans are under pressure not to agree to any deal unless it blocks health insurance plans bought using the subsidies from covering abortion — but that idea is anathema to Democrats.
Susan B. Anthony Pro-Life America, a leading antiabortion group, has threatened to try to unseat any Republicans who vote for a bill that does not include abortion restrictions, known as Hyde protections. The group targeted antiabortion Democrats who voted for the ACA in 2010 on the same grounds.
Many Republicans — including Thune and Johnson — have insisted that any health care bill must include Hyde language.
“I would never consider any form of subsidy extension without Hyde protections,” said Rep. Andy Harris (R-Maryland), the chairman of the conservative House Freedom Caucus.
Democratic and Republican senators are still discussing a potential compromise, and Thune has expressed optimism that those talks could gather momentum once the dueling bills failed.
Sen. Jeanne Shaheen (D-New Hampshire), who has been involved in the talks, said Wednesday that it was hard to see how such a bill could come together before subsidies expire at the end of the year, although Congress still could pass legislation in January.
“I think there is a path to get a compromise bill,” Shaheen said. “The question is whether there’s a commitment to do that on both sides of the aisle, and that’s not clear yet.”
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