The GOP just trotted out its fourth Obamacare replacement attempt

Fourth time’s the charm?

Republicans unveiled the fourth version of Trumpcare on Thursday with changes meant to entice the Republicans who refused to support Senate Majority Leader Mitch McConnell’s last bill three weeks ago.

The core of the legislation remains the same: large cuts to Obamacare’s insurance subsidies, a roll back of Obamacare’s Medicaid expansion that has helped insure over 10 million people, cuts of many Obamacare taxes, and an conservative overhaul of Medicaid that would cap the amount of money and give states control over the program.

But McConnell has made significant changes to the bill in order to get the support 50 of the 52 Senate Republicans to vote “yes.” Here is a rundown of the changes, according to a summary first obtained by the New York Times and confirmed by VICE News:

• $70 billion more to help cover out-of-pocket costs.
• An exception to Medicaid spending caps in the case of a public health emergency (Zika, for example)
• $45 billion to combat the opioid crisis (experts say this is woefully insufficient to combat the crisis and will not offset the enormous Medicaid cuts).
• Allows people to use Health Savings Accounts to pay for insurance premiums.
• Taxes on investment income and a supplement Medicare payroll tax on the wealthy will remain in place. Past versions of the bill had cut those taxes which many Democrats and some Republicans criticized as a giveaway to the wealthy while cutting benefits.
• It leaves in place the limits on tax deductions that can be taken by top executives at insurance companies.
• People can obtain health insurance subsidies for so-called “catastrophic plans.” These bare bones insurance plans were not allowed under Obamacare because they did not cover what the government considered “essential health benefits,” such as hospitalization and maternity care. Experts have expressed concern that this would bifurcate the market with healthy people migrating to these plans and then premiums skyrocketing for sicker people.

Sen. Rand Paul of Kentucky preemptively came out against the bill yesterday, telling reporters that “the new bill is the same as the old bill, except it leaves in place more taxes.”

Without Paul’s support, McConnell can only lose one more vote. Paul previously supported simultaneous repeal and replace of Obamacare but has become disillusioned with Trumpcare’s slimmed down version of Obamacare’s insurance subsidies. “I’m not voting to create new entitlements for insurance companies,” Paul told Fox News Thursday.

Fellow conservative Sen. Ted Cruz of Texas, who had been against the previous Trumpcare iteration, was more optimistic about this new version because of the new catastrophic plan provisions. “That’s a big deal for lowering premiums and for consumer freedom,” he told the Associated Press. The change had been inspired by an amendment he proposed along with Sen. Mike Lee of Utah.

But the new bill still reduces Medicaid spending by several hundred bill dollars which may be unpalatable to Republicans representing rural areas or places particular affected by the opioid epidemic. Republicans from Ohio, Kansas, Alaska, North Dakota, Maine, West Virginia, Nevada, and Louisiana have all express deep reservations about the Medicaid cuts.

Sen. Rob Portman of Ohio and Sen. Shelley Moore Capito of West Virginia — who opposed the last bill because of its potential to exacerbate the opioid crisis in their states — have already suggested that the extra $45 billion won’t be enough.

“More opioid funding would be very good, very beneficial, but the core for me is the Medicaid provisions,” Capito told Vox in June. “You can grant the state more money for treatment, but if you can’t access the treatment, it’s not going to do you any good.”