Six months into Donald Trump’s Presidency, Republican legislators have taken major steps to deliver on promises to repeal the Affordable Care Act (ACA) that was implemented under President Barack Obama. However, they seem to have been stymied by internal Republican politics and a groundswell of public opposition, in terms of getting their repeal plans across the finish line.

In May, the U.S. House of Representatives approved a bill, the Affordable Health Care Act (AHCA), which would dramatically impact the American health care system by cutting back on the ACA’s expansion of Medicaid. The AHCA also allows states to opt out of requiring insurers to provide certain basic health benefits, allows for higher premiums for pre-existing conditions, eliminates tax penalties for individuals without health care coverage and for employers not offering health coverage to their employees, and allows replacing tax credits and premium subsidies for lower income individuals with significantly more limited tax credits.

The AHCA is seen as having no chance of garnering enough votes in the Senate, proving to be overwhelmingly unpopular among people across the political spectrum and being labelled as “mean” even by President Trump, who urged the Senate to produce a plan “with heart.” Senate Republicans, instead, introduced their own version of a healthcare reform bill, the Better Care Reconciliation Act (BCRA), in late June after an extended period of drafting by a select group of Republican Senators outside the scrutiny of the public and even of fellow Senators.

While the Senate was initially expected to produce a version of “repeal and replace” that would fare better with moderates than the House version, it seems that the Senate bill that emerged from the secretive drafting group has missed its mark. According to the New York Times, the BCRA would, like the House bill, roll back much of the ACA legislation, including the expansion of the Medicaid program, which currently covers millions of low-income Americans, and the mandate that most U.S. citizens have health insurance. The BCRA would not only phase out the expansion of Medicaid in 2021, but it would also reduce Medicaid spending even more than the House bill would over the long-term. The Senate bill would maintain the ACA subsidies for a narrower group of lower-income individuals for a short transition period, but then would eliminate the subsidies in 2020.

Knowing how unpopular their bill would be even with their own supporters, the Senate sought to rush the legislation to a vote by the end of June so that Senators would not have to face their constituents during the 4^th of July break, which could cause some Republican Senators to lose resolve and turn against the bill. The failure of the Senate to produce a more moderate version of health reform legislation – as punctuated by a recent Congressional Budget Office (CBO) report on the bill – ultimately forced Senate Majority Leader Mitch McConnell to back away from this rush to vote and only lessening Republicans’ chances of passing a Senate bill that completely replaces the ACA.

The CBO report released June 26 found that the proposed Senate healthcare bill would cut Medicaid by $770 billion over a ten-year period. Lower federal spending on Medicaid would eventually lead to more people being left without coverage. The CBO estimated that 15 million fewer people would be enrolled in Medicaid by 2026 due to the proposed decrease in Medicaid spending alone. In addition, another 7 million fewer people would obtain individual health insurance policies beginning in 2018 due in large part to the elimination of the individual coverage mandate.

The CBO report also revealed the devastating effects for low-income and older Americans under the proposed Senate bill. The BCRA provides for lower premium assistance and would thus cause the out-of-pocket cost of premiums for low-income and elderly individuals to go up. According to the CBO report, this would, in turn, lead many lower income individuals to trade their current healthcare plans for lower cost plans with less generous coverage. Such plans would have more manageable premiums, but also have much higher deductibles, co-pays, and exclusions. Thus, low-income Americans would have to pay substantially more for health care or else settle for much worse coverage. Many people are expected to drop coverage altogether due to the high expense and low coverage offered by the plan.

For these combined reasons, the CBO reported that a projected 22 million people could lose coverage over the next decade under the proposed plan. Yet the overall number of Americans covered by Medicaid or private insurance under the bill is not the only likely negative impact of this plan. The CBO report also raises concerns about the quality of coverage under the BCRA.

According to Axios, while the Senate bill would still require insurers to cover individuals with pre-existing conditions without charging higher premiums, the insurers would be free to provide lower benefits that could in some cases negate the value of the insurance. In addition, while the current ACA ensures that health plans cover ten categories of benefits, the Senate bill would allow states to obtain waivers so that they could set their own minimum benefits. The bill would repeal the mandate that employers with over 50 workers must provide coverage that meets affordability standards or else face penalties. While young healthy individuals may see their insurance costs fall under the Senate plan (or might altogether forego obtaining insurance), older or less healthy individuals face the likelihood of considerably higher overall health costs through the combination of premiums and other out-of-pocket expenses.

According to the Atlantic, the BCRA currently faces fierce opposition from some Senate Republicans at both ends of the political spectrum. The most conservative Republicans believe that the minimum benefits that would be required by insurers should be eliminated, while moderate Republicans have voiced their concerns about loss of coverage and affordability for older and low-income individuals. Senator Rand Paul of Kentucky opposes the proposed legislation due to the minimum requirements, viewing such requirements as a means of making health care a permanent entitlement, while also expressing concerns that the bill did not do enough to reduce the deficit.

Senators Mike Lee of Utah and Ted Cruz of Texas, both conservative Republicans who oppose the bill in its current form, are currently drafting a “Consumer Choice” proposal that they hope would serve as a compromise with moderate Republicans. Their proposal would allow insurers to offer more health insurance choices for individuals in addition to plans that meet the minimum benefits requirements, including plans that do not meet such requirements. They argue that this would increase competition and lower costs, while opponents express concern that this would increase pressure on individuals to choose non-compliant plans due to costs and thereby undermine overall quality standards.

Majority Leader Mitch McConnell, who initially led the drafting of the BCRA to appeal to conservatives, needs to secure 50 votes in the Senate to get the bill passed under reconciliation rules (as opposed to the normal 60 vote threshold). The CBO’s report found that the BCRA would reduce direct spending and revenues such that there would be a “net reduction of $321 billion in the [federal] deficit” over the proposed 2017-2026 period. Under reconciliation rules, the projected savings provide Senator McConnell with an opportunity to win converts to his bill by offering amendments that may appeal to holdouts. Senator McConnell has already tried to appeal to moderates in this way by offering to include $45 billion to combat opioid addiction in the US at the requests of Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia.

The issue of funding for Planned Parenthood is another potential area where McConnell might compromise in order to gain more votes. The New York Times reports that Senators Susan Collins of Maine and Lisa Murkowski of Alaska, both moderate Republicans, are opposed to the current version of the bill, including its provision that would defund Planned Parenthood. The proposed Senate bill has been labelled by Planned Parenthood as “the worst bill for women’s health in a generation.” It would strip Planned Parenthood of Federal funding for a year and bar the use of federal tax credits for private health plans that cover abortions. This provision seems counterintuitive; Republicans are seeking to maximize deficit reduction through the Senate bill, yet the CBO reported in March that cutting Planned Parenthood funding would actually increase federal spending due to increased births covered by Medicaid. While Senators Collins and Murkowski would view the reinstatement of funding for Planned Parenthood as fundamental, it is not clear whether this would be sufficient to win their votes. Further, while it is unclear whether these concessions will be enough to win over moderates, it is also possible that they may drive away support from conservatives.

In recognition that Senator McConnell may not be able to reach a satisfactory compromise on the current bill, some conservatives, including Senators Ben Sasse of Nebraska and Rand Paul of Kentucky, have brought back the idea of “repeal now and replace later.” This approach, while allowing Republicans to vote now to fulfil their promise to repeal the ACA as of a specific date in the future, would create pressure to come together on a health plan by setting a deadline by which action must be taken before the ACA provisions would terminate. President Trump tweeted his endorsement of this approach on Friday morning.

The current fight for healthcare reform in the United States is immensely divisive. At times, it seems as though US leaders are simply pursuing relatively small political victories without regard to the impact on their constituencies. Republicans are deeply entrenched in the politics of deconstructing former President Obama’s legacy when they should be working across the aisle to create a bill that benefits Americans, especially those who are the poorest and most vulnerable. Legislators should implement a plan that provides high-quality health care for the greatest quantity of people; it should not be a matter of debate. The Senates’ bill has the potential to significantly decrease the quality of coverage for low-income individuals, as well as the potential for millions of Americans to lose coverage under the bill, should be of a major concern to all US Senators.

Last week, Politico reported that Senator McConnell “threatened” Republicans that if the ACA repeal by the proposed Senate bill failed, they would be “forced” to work with Democrats. It is a sad commentary on the state of political leadership in Washington that Senator McConnell would threaten his Republican colleagues with what would, in fact, be the best approach to making the improvements to the health system that are needed, which is to work cooperatively with both parties to achieve what is best for the American people.