Sen. Susan Collins criticized the secretive process that her Republican colleagues in the Senate are using to craft a replacement to the Affordable Care Act, and said she will not vote for the bill if it hasn’t been analyzed by the Congressional Budget Office.

The American Health Care Act, the replacement bill passed by the House, was approved by lawmakers before it received its CBO score.

In an interview with the Portland Press Herald on Friday, Maine’s senior senator said that the 13 Senate Republicans drafting the bill – an all-male group led by Majority Leader Mitch McConnell of Kentucky – should not be doing so behind closed doors.

Collins said a poor score for the House replacement bill, which the nonpartisan CBO estimated would result in 23 million Americans losing health care coverage by 2026, was among the many reasons she voiced her opposition to the bill. She said her goal is for more people in the United States to have health care coverage, not fewer.

“I’m not going to vote for a bill whose impact has not been analyzed by the CBO,” Collins said. “I think that it is not a responsible way to legislate, when you don’t know the impact on cost and coverage. I always believe legislation is best crafted through the normal order. I think it’s much better to have committee consideration of bills, public hearings and to have a full debate. That’s the process for most well-considered legislation.”

When and how Senate Republicans will reveal the contents of their replacement to the ACA is unknown, but recent national news outlets have been reporting that McConnell wants a vote before the July 4 recess or sometime later in July.

Andy Slavitt, a former Obama administration official who headed up the U.S. Centers for Medicare and Medicaid Services, said in a series of tweets Thursday that there are reports that McConnell will release the text of the bill and the CBO score simultaneously, within a few hours of a Senate floor vote.

Other news outlets, including The Washington Post and The New York Times, have reported that Republicans are working at breakneck speed to get a bill in front of the Senate before the opposition has a chance to coalesce.

Collins, however, said she would prefer a much more deliberative process, hearing from experts and those directly affected by the bill, such as hospitals, insurers and state officials.

Collins said she’s been kept in the dark, except for one meeting with the Republican lawmakers, which she described as a “fragmentary outline.”

Collins said it does seem like the Senate bill will be an improvement on the House bill, but that’s not an endorsement of the Senate bill.

“There’s so many questions and unfinished provisions that I by no means can be sure that it would be a bill I would support,” she said. “Having it be better than the House bill is a pretty low bar.”

Collins also reiterated her support for Planned Parenthood, and opposition to de-funding of the agency, which media outlets have reported is part of the Senate bill.

Mitchell Stein, a Cumberland-based health policy consultant, said he was pleased to see that Collins is trying to slow down the process, which he said will help Congress come up with something better, or it could stop a bad bill from becoming law.

“They know how unpopular this is going to be and so they’re rushing it through as quickly as possible,” Stein said. He also said the point of the Senate bill is not to improve health care in the United States, but to provide tax cuts for the wealthy by unwinding the ACA.

Collins is a key vote in a closely divided Senate, where it would take three Republican defections to scuttle a replacement of the ACA. Collins and Sen. Bill Cassidy, R-Louisiana, have introduced a moderate bill to replace the Affordable Care Act, but the bill that seems to get the most attention is the bill being worked on by the McConnell working group.

The ACA has resulted in about 20 million more Americans gaining insurance, through Medicaid expansion and the individual marketplace. The uninsured rate has declined from about 18 percent before the bill went into effect to 11 percent in 2016, according to Gallup polling.

About 80,000 people have ACA insurance in Maine, where the uninsured rate is 9.1 percent. The state has so far not expanded Medicaid – insurance for the low-income and disabled – but a referndum will go before voters in November that if approved would result in Medicaid expansion.

Collins has praised the benefits of Medicaid expansion, especially in states like Indiana that have approved a modified version that requires more cost-sharing by low-income residents. Medicaid is typically free for those who qualify.

But Collins did not close the door on agreeing to some form of a rollback on Medicaid expansion. While the content of the Senate Republicans’ bill remains secret, news has leaked out that it would still end the Medicaid expansion, but rather than do it immediately, would take three to seven years to end the expansion.

“I really want to see the specifics,” Collins said. “There’s a big difference between cutting people off and doing it quickly versus giving states and providers an attempt to come up with a system over seven years.”

Collins said there may be room for compromise on the formula for how Medicaid expansion is funded. For states that expanded Medicaid to those earning up to 138 percent of the federal poverty limit, the federal government is paying 90 percent or more of the cost of expansion. Typically, the federal government pays about two-thirds of the cost, with the states picking up the rest.

“I think there are ways to figure this out. Perhaps it doesn’t drop all the way to what the normal federal match would be,” Collins said.

Collins also is worried about how a replacement bill would affect not just expansion populations, but the entire Medicaid population by changing the underlying formula for how Medicaid is funded. A stingier funding formula could harm rural hospitals and health services.

“That has enormous implications,” Collins said. “We’re not just talking about expanion states or just the expansion population. We’re talking about the entire Medicaid population.”

Collins does believe government can operate Medicaid more efficiently.

“I do think there are reforms in Medicaid that would improve health outcomes and lower costs,” Collins said.

Separate from the Senate bill, Collins also criticized the Trump administration for not being forthcoming about plans for cost-sharing subsidies that help people who earn 250 percent or less of the federal poverty level buy insurance on the ACA’s individual marketplace.

Collins said that by being vague about the subsidies, the administration is causing insurance companies to set their rates higher for 2018 than if the companies knew that the subsidies would continue to be paid at the same rate.

“Another cause of instability in the marketplace is the fact that the administration has been sending very conflicting signals on the cost-sharing reductions,” Collins said.

Joe Lawlor can be contacted at 791-6376 or at:

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