Senate Republicans' bill to repeal and replace the Patient Protection and Affordable Care Act delivered few surprises but drew deadly opposition, putting Kentucky's senators on opposite sides.

“I’m pleased that we were able to arrive at a draft that incorporates input from so many different members, who represent so many different constituents, who are facing so many different challenges," Majority Leader Mitch McConnell, who directed drafting of the bill by Republicans in secret, said in a floor speech.

Republicans hold 52 of the 100 Senate seats, so McConnell can afford to lose only two votes in his own party, and four Republicans -- including Rand Paul of Kentucky -- announced that they are opposed to the current version.

“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation," the senators said in a statement. "There are provisions in this draft that represent an improvement to our current health-care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”

Senators joining Paul were Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah. There was some doubt about the strength of Cruz's opposition. President Trump said the bill "is going to be negotiated."

Paul told Kelsey Snell of The Washington Post, "The bill looks like we are going to keep all of the Obamacare subsidies — in fact, we may well exceed the Obamacare subsidies. That’s a problem. The bill establishes new money — about $130 billion — for what they call a 'stabilization fund.' That money is going to go to insurance companies that make a $15 billion profit. I find it unconscionable that we’re going to give money to insurance companies that make a $15 billion profit. Those two things don’t look like repeal to me."

If the bill passes the Senate and House and is signed by Trump, two of the biggest impacts in Kentucky would be a phasing out of the state's 2014 Medicaid expansion by 2024, followed by cuts to traditional Medicaid in 2025.

Kentucky is one of 31 states that expanded Medicaid to anyone with household income up to 138 percent of the federal poverty line, $12,060 for an individual and about $33,000 for a family of four. Medicaid covers 1.4 million Kentuckians, 470,000 of them through the expansion.

Under a repeal-and-replace bill passed by the House, Medicaid expansion would end in 2020. Under the Senate bill, it would remain the same until 2021, but would be phased out over the following three years.

Then, federal support for traditional Medicaid would decrease, because it would have spending limits based on population rather than reimbursing a state a percentage of whatever it spends, based on a formula that gives poorer states more money. In Kentucky, the federal government pays about 70 percent of costs for traditional Medicaid recipients and 90 to 95 percent for expansion members.

"The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s," Julie Rovner reports for Kaiser Health News. "That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs."

Kentuckians who buy private, subsidized health insurance on the federal exchange would also be affected by the Senate bill. During the 2017 open enrollment period, 81,155 Kentuckians enrolled for coverage through the exchange and four out of five of them received a subsidy to help pay for their premiums, according to the Kentucky Center for Economic Policy.
The 142-page bill would lower the qualifying level for people to get subsidies, starting in 2020, to 350 percent of the poverty line from 400 percent (about $94,000 for a family of four).

The bill also eliminates billions of dollars in taxes, mostly for the wealthy and the health-care industry, that are being used to pay the subsidies and the cost of the Medicaid expansion. The proposed tax cuts drew fire from Democrats.

“As the Senate proved again today, Trumpcare’s core mission is not to provide health care to Americans, but to give millionaires tax breaks and fundamentally end Medicaid as we know it," Democratic U.S. Rep. John Yarmuth of Louisville, said in a statement. "The results would be devastating for families: millions of Americans would lose coverage, key health-care protections would be taken away, and crucial services for seniors needing long-term care, children with disabilities, people struggling with addiction, and low-income families would be eliminated."

Jason Bailey, executive director of the Kentucky Center for Economic Policy, said in a statement: "No state has more to lose from this bill than Kentucky because no state has achieved more health and coverage gains in the last few years thanks to the Affordable Care Act. The bill would reduce Kentuckians’ health, harm the state’s most vulnerable and set us further back on fighting Kentucky’s opioid crisis. It will result in less coverage at higher cost, especially for poorer, older and sicker people. It will also lead to substantial job loss at hospitals and doctors’ offices and weaken Kentucky’s rural economies in particular."

In his floor speech, McConnell cited increases in premiums for Obamacare policies and said the 2010 law isn't working. "More Americans are going to get hurt unless we do something," he said. "American families deserve better than its failing status quo — they deserve better care."

The Senate bill would keep the Obamacare provision allowing children to stay on their parents' insurance policies until they turn 26. It would also keep the requirement for insurers to cover those with pre-existing conditions and charge them the same regardless of health history. However, it would allow states to waive some consumer protections such as the 10 essential health benefits, like maternity care and mental health treatment, that Obamacare requires in all insurance plans.

"This would allow insurers to offer less comprehensive policies, so those with pre-existing conditions may not have all of their treatments covered," CNN reports.

The bill also allows states to apply for federal waivers to eliminate the Obamacare mandate that barred insurers from setting a lifetime limit on an individual's benefits, reports the New York Times. 

The bill would repeal the individual and employee mandates for buying health insurance. It would allow insurers to charge older people five times as much as younger ones; the current limit is three times. It would de-fund Planned Parenthood for one year.