âThat is going to cause a lot of harm, and thatâs one of my biggest concerns about the bill,â Senator Susan Collins, Republican of Maine and a crucial holdout on the bill, told CNN after the release.
For Republican leaders who say Medicaid spending is unsustainable, the findings might be seen as evidence that their policies would work. They want to put annual caps on Medicaid spending and roll back the expansion of the program, which has extended coverage to millions of people in 31 states.
But for Republican senators from some of those states, including Nevada, Ohio and West Virginia, the pain of those cuts may prove politically untenable.
Hoping to revive their repeal bill, Senate Republicans said on Thursday that they were seriously considering proposals to keep one of the lawâs taxes on high-income people while providing more money to combat the opioid epidemic and a new incentive for people to establish tax-free savings accounts for medical expenses. Ms. Collins said Republican leaders and Trump administration officials had agreed to $45 billion for an opioid treatment fund.
Republicans also said they were considering a proposal that would allow insurers to sell cheaper, less comprehensive health plans if they also offered at least one plan that complied with consumer protection standards like those in the Affordable Care Act.
The talk of leaving in place a tax on investment income was a big break from the House-passed health bill and from the Senateâs approach.
âItâs not equitable to have a situation where youâre increasing the burden on lower-income citizens and lessening the burden on wealthy citizens,â said Senator Bob Corker, Republican of Tennessee. âThatâs not a proposition that is sustainable, and I think leadership knows that.â
But for every concession made to one senator, another senator seemed to balk.
âWe pledged that we would repeal Obamacare. I donât remember anybody going around saying, âOh, except for these job-killing tax increases,ââ Senator Patrick J. Toomey, Republican of Pennsylvania, said of the talk of leaving the investment tax increase in place. âSo I expect that weâll be repealing all of the taxes in Obamacare.â
The negotiations themselves are attracting controversy, and personal strains are showing.
Mr. McConnell dressed down Senator Rob Portman, Republican of Ohio, this week over his resistance to Medicaid cuts. Senate Republicans bristled after an outside group tied to Mr. Trump went after one of their own for opposing the bill, Senator Dean Heller of Nevada. Adding to the insult, one of the top officials of that group, Nick Ayers, was named Vice President Mike Penceâs chief of staff on Thursday â after the blowup.
Democrats are also angry. For seven years, Republicans have denounced what they call corrupt deals made by Senate Democrats to buy votes for passage of President Barack Obamaâs health care bill.
The frantic wheeling and dealing among Republican senators on Thursday had more than a faint resemblance to the negotiations that led to adoption of the health care law in 2010.
âThe slush fund is open,â said Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, referring to about $200 billion that could be available for deals in the Senate repeal bill. âApplicants can queue up and have a good chance of being treated favorably if they are from the right political party.â
Mr. McConnell briefed senators on Thursday about possible changes in the repeal bill, but the broad agreement he had hoped for appeared elusive. He scrapped plans for a vote on the bill this week after he met broad resistance from Republican senators across the ideological spectrum.
Republicans were talking publicly on Thursday about keeping a tax on capital gains and other investment income, imposed by the Affordable Care Act on individuals with annual incomes exceeding $200,000 and couples making more than $250,000.
Mr. McConnellâs bill would repeal that tax, like most other taxes in Mr. Obamaâs health care law. The Congressional Budget Office said that repealing the investment tax, retroactive to the start of this year, would cost the government $172 billion in lost revenue from 2017 to 2026.
Ms. Collins said, âI do not see a justification for doing away with the 3.8 percent taxâ on certain investment income. She said the investment tax differed from other taxes in the Affordable Care Act, like an excise tax on medical devices, because those taxes can increase costs for consumers. âI distinguish between those tax increases that were part of Obamacare that increase premiums and the cost of health care versus those that donât,â she said.
Mr. Corker said that the initial Senate bill would leave health care out of reach for many lower-income people and that keeping the tax on investment income would provide revenue that could be used to address that issue. The Congressional Budget Office said the bill could increase costs for low-income people to the point that âfew low-income people would purchase any plan,â even with financial assistance from the government.
The money for drug abuse treatment â $45 billion over 10 years â was meant to woo wavering Republicans from states hard hit by the opioid epidemic, including Mr. Portman and Senator Shelley Moore Capito of West Virginia.
But Senator Maggie Hassan, Democrat of New Hampshire, another state hit by the opioid crisis, said the additional money was âa drop in the bucket that would not come close to making up for the damageâ that could be done by the billâs cuts in Medicaid.
The Congressional Budget Office said that over 10 years, Mr. McConnellâs bill would cut more than $770 billion from projected spending under Medicaid, a program that pays for a large share of substance abuse treatment and prevention costs in many states.
Another proposal, championed by some conservatives, would allow people to use money in health savings accounts to pay premiums for insurance policies, not just medical expenses.
Christopher E. Condeluci, a former tax and benefits counsel at the Senate Finance Committee, said the change would make health savings accounts more attractive to people who could afford to put money into them. Such savings accounts have become more important, he said, as more Americans have high-deductible health plans, which require them to pay a larger share of their medical costs.
Senate Republicans are also considering a plan from Senator Ted Cruz, Republican of Texas, intended to create lower-cost insurance options. Under the proposal, if an insurer offered at least one plan that met certain federal requirements, offering benefits like maternity care and mental health services, it could also sell insurance policies that did not meet those standards.
Mr. Cruz says the proposal would allow consumers to buy policies they desire and can afford. But insurance experts see a risk that healthy people might sign up for the low-cost, less comprehensive policies, leaving sicker people in the more expensive plans. Republicans said there were ways to minimize that risk.