WASHINGTON — Democrats may not have the votes to stop the Republican push to repeal the Affordable Care Act, but they do have the Senate rules.
In the Senate, the rules are often seen as sacrosanct and members of both parties are quick to use them for partisan advantage. One of the rules, originally intended to speed consideration of budget measures, also limits what can be included in such bills. And Democrats plan to use that rule to challenge major provisions of the Republican repeal bill.
Senators can object to a provision if it does not change federal spending or revenues or if the budgetary effects are “merely incidental” to some policy objective.
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That rule could be tested soon. The Senate majority leader, Mitch McConnell, Republican of Kentucky, has set the health bill for debate and a vote on the Senate floor next week. And he has promised a new version of the bill on Thursday, in hopes of winning support from Republican senators who have criticized the latest iteration for a variety of reasons.
Republicans and Democrats are making formal presentations this week to the Senate parliamentarian, Elizabeth MacDonough, who serves as a sort of referee, deciding whether specific provisions of the bill comply with Senate rules. Provisions that flout the rules could be removed before or after the bill goes to the floor, and that could affect who votes for the measure.
Democrats are preparing to challenge these provisions, among others:
• Planned Parenthood: The Senate Republican bill would cut off federal Medicaid funds for Planned Parenthood for one year. The Congressional Budget Office says this would reduce federal spending by $225 million, of which more than one-third would be offset by higher costs for additional births to women covered by Medicaid. Democrats say the policy goal outweighs the budgetary impact.
• Age ratios: The Senate bill would let insurers charge older consumers five times as much as young adults. Under the Affordable Care Act, they can charge no more than three times as much. Democrats say the purpose of the change is purely regulatory, not budgetary. The proposal could affect anyone in the individual insurance market, not just people receiving federal subsidies.
• Waiting period: People who went without insurance for approximately two months in the prior year would be required to wait six months before they could start coverage under the Senate bill. Democrats say the purpose is not to save money, but to regulate insurance and to encourage people to obtain coverage without imposing an “individual mandate.”
• Abortion coverage: The bill would prevent consumers from using federal tax credits to help pay premiums for insurance that included coverage of abortion. Republicans say this could save money. But Democrats say that the Republican goal is to regulate insurance and to reduce abortions, and that the proposal would not affect federal spending.
Democrats are also expected to challenge a provision of Mr. McConnell’s bill that would allow states to impose work requirements on some Medicaid beneficiaries
And they are prepared to challenge a proposal by Senator Ted Cruz, Republican of Texas, that would allow insurers to sell stripped-down insurance, free of most federal regulations, if they also offered at least one plan that complied with insurance standards like those in the Affordable Care Act. Health plans could, for example, omit coverage of maternity care or mental health care.
Some Republicans say the noncompliant plans would have lower premiums, so the government would spend less on subsidies. Democrats say the budgetary impact is merely incidental to the policy purpose, which they say is to deregulate insurance.
Groups representing patients and insurance companies flooded Senate offices on Wednesday with correspondence opposing Mr. Cruz’s proposal. “The Cruz proposal would result in higher, not lower, premiums for people with serious and chronic conditions,” said a letter from 13 patient advocacy groups including the American Heart Association and the lobbying arm of the American Cancer Society.
Scott P. Serota, the president and chief executive of the Blue Cross and Blue Shield Association, said the Cruz proposal “would create two sets of rules for health insurance products” and could make coverage unaffordable for people with pre-existing conditions who need more comprehensive insurance policies.
Senator Rand Paul, Republican of Kentucky, said the revised version of Mr. McConnell’s bill was no better than the original.
“The new bill is a lot like the old bill,” Mr. Paul said. “But it leaves in place more taxes, increases taxpayer subsidies to buy insurance and adds about $70 billion to an insurance bailout superfund.”
“At this point,” Mr. Paul said, “I cannot support the bill.”