Healthcare in Focus As Final Tax Reform Vote Nears

Sen. Susan Collins (R-Maine) has made healthcare a primary aspect of the tax reform debate. 

The fate of the Republican tax reform bill, which is in reconciliation between the House of Representatives and Senate, relies on a number of potential scenarios—some of which could carry major implications for healthcare.

The revised legislation is expected to be introduced Friday and eliminate the Affordable Care Act’s individual mandate. Nearly $400 billion in cuts to Medicare over the next decade might be included as well.

Healthcare has become a primary aspect of the tax reform debate due to Sen. Susan Collins (R-Maine) who has made her vote contingent on a number of provisions relating to the future of the ACA. These include proposed cuts to Medicare and the continuation of cost-sharing reductions (CSRs) to support the insurance markets.   

Senate Majority Leader Mitch McConnell (R-Ky.) and House Speaker Paul Ryan (R-Wisc.) are aiming to vote on the measure next week ahead of another vote to avoid a government shutdown.

Currently, there are 52 Republicans and 48 Democrats in the Senate. Most GOP senators have signaled support for the bill, but Sen. Bob Corker (R-Tenn.) voted against the original bill and has indicated he is unsure whether he can vote for the reform package, citing concerns over its effects on the national debt.

Collins remains the most prominent wild card in the legislative equation, as she has not indicated which way she will vote. Collins voted for the original Senate version of the tax reform bill after receiving a promise from McConnell and Ryan that the triggered Medicare cuts will not occur.

Another sticking point for Collins are CSRs, which were discontinued by the Trump administration earlier in the fall. The move was a striking blow to a key financial mechanism to the ACA.  

If every Republican senator except Corker and Collins were to vote in favor of the final bill, resulting in a 50-50 vote, Vice President Mike Pence could act as tiebreaker. The White House announced Thursday that Pence’s trip to the Middle East has been delayed so he can step in should such a situation arise.

Republicans are also well aware that they will lose a vote when Acting Sen. Luther Strange (R-Ala.) is replaced by Sen.-elect Doug Jones (D-Ala.). Jones defeated Republican candidate Roy Moore in the special election Tuesday to fill the seat formerly held by Attorney General Jeff Sessions.

Due to Alabama election laws, December 27 is the earliest Jones could take office. When that happens, the Senate’s composition will shift to 51 Republicans and 49 Democratic votes.

Assuming Corker remains a defection on the tax bill, Republicans would need to keep Collins in the fold in order to maintain 50 votes so Pence can cast the deciding vote.    

Political negotiating aside, Sen. John McCain (R-Ariz.), who is expected to vote for the tax reform bill, remains a wild card due to his health. McCain was diagnosed with brain cancer in July and missed several votes this week due to a hospitalization to address side effects and receive treatment at Walter Reed Hospital.

Additionally, Sen. Thad Cochran (R-Miss.) has missed votes recently due to medical issues.