This week, it’s all about health care – repealing the Affordable Care Act and replacing it with… well, something.

The House passed its version of a health care bill (H.R. 1628) in May. Senate leaders had planned to move quickly and efficiently on their version, but prospects for quick passage are dimming.

Status Note: In the Senate, there are 52 Republicans, 46 Democrats and 2 Independents who caucus with the Democrats. Because this bill is on a “fast track” process designed for tax bills (called the “reconciliation” process), the Senate only needs a bare majority of 51 to pass this legislation, instead of its usual 60-vote self-imposed requirement.

As of now, all Democrats (and Independents) and 9 Republicans have announced opposition to the bill. [Note: while this article was being posted, the number of dissenting Republican senators rose to 12.] The Majority Leader, Senator Mitch McConnell, has pulled the bill from the floor until after the July 4 recess.

The People

Yesterday afternoon, faith groups came together to begin a 23-hour vigil outside the Capitol building, to open the space for a moral response to the nation’s health care needs. Around the country, people are writing, calling, tweeting, and sharing messages on social and print media.

Last night, a pop-up rallystarted with a Senator (Booker - NJ) and a Representative (Lewis – GA) sitting together on the Capitol steps, talking with each other and tweeting to their networks about the damage this bill would do to American families. People stopped by, joined in the conversation, shared their stories, and expressed their outrage and worry at the prospect of losing their health care access. Eventually, there was quite a crowd!

Senators from both parties are hearing these messages and some are withdrawing their support. Senators Collins (ME), Portman (OH), Murkowski (AK), and Moran (KS) are calling for more careful consideration and an open process. Senator Collins remarked that the “Senate bill doesn’t fix the ACA (Affordable Care Act) for rural Maine.” Senator Murkowski, similarly, spoke of concern for many very rural Alaskans who rely on Medicaid. Senator Heller (NV) said “This bill will mean a loss of coverage for millions of Americans and many Nevadans. These are folks who are worth fighting for.”

Meanwhile, four senators feel that the bill does not go far enough to remove government from the insurance business. They advocate more generous provisions for medical savings accounts, and tax breaks for households with incomes below the federal poverty line, to help them pay for private insurance premiums. (These provisions, of course, would only assist low-income people who have enough money to set aside significant “medical savings” to cover medical bills, or who pay significant federal tax bills in spite of their minimal income…a fairly small group.)

In addition, governors are weighing in. They have to deal with implementing health care within their budgets, and they tend to be more knowledgeable than many senators on the mechanics and economics of health insurance. Ohio Governor John Kasich, for example, joined in a press conference with Colorado Governor John Hickenlooper, calling the Senate bill “unacceptable,” saying it would “result in loss of coverage for millions and millions of people,” particularly people who are mentally ill, drug addicted, or chronically ill. The bill gives a lot of money “to people who are already very wealthy” and denies resources to health care programs.

The Bill - Detailed Resources Now Available

Until six days ago, when Senate leaders finally decided to release the details of the bill, we could only guess what was in the bill. In fact, most senators themselves could only guess, as they also had been kept in the dark. On Thursday the 22d, a draft of the Senate bill was made available.

This week, the Congressional Budget Office (CBO) - Congress’s advisory arm on the financial impact of legislation – released its report. The CBO said that 22 million people who have insurance coverage now would be left without access to health care.

We know now that the Senate bill would cut even more deeply into Medicaid and leave more people without health care access.

Three national Native American organizations – the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), the National Council of Urban Indian Health – wrote to Senate leaders in response to the new Senate bill. The letter reminded senators of the federal trust responsibility, “agreed to long ago and reaffirmed many times by all three branches of government, to provide healthcare to Tribes and their members. Both Medicaid and IHS (Indian Health Service) funding are part of the fulfillment of the trust responsibility.”

The letter specifically asks that the expansion of the Medicaid program be continued, and that work requirements for Native American and Alaska Native Medicaid participants be dropped from the bill. The “per capita” formula for Medicaid funding should not be applied to services received through the Indian Health Service, and should be based instead on need. And finally, funding needed to support cost-sharing protections and preventive and public health programs should be included.

Our colleagues at the NIHB have also posted an action alert and a very useful chart comparing health care access under current law (with Medicaid and the Affordable Care Act intact), under the House bill, and under the Senate proposal.

The NIHB has concluded that it cannot support the Senate proposal, because of the devastating effect on Medicaid. Medicaid is an essential payer for care provided by the Indian Health Service, and the funding provided for Medicaid in the Senate bill is even lower than in the House bill. Without that support, NIHB concluded, the Indian Health Service “will not survive.”

The permanent authorization of the Indian Health Service would continue, however, (regardless of a lack of adequate funds), as would several provisions specific to tribes and Indian health care participants.

Given the unmet trust responsibility and the chronic under-funding of the Indian Health Service, the national organizations’ letter says, “the Senate should pass reform legislation only if it does not reduce access to care for [American Indians/ Alaska Natives], or further strain the already stretched resources of Indian Health Service, Tribally-operated, and Urban Indian health programs.”

The Moment

This moment is very fluid. The Senate does not have the votes to pass this bill, and the primary reason is that it harms too many people. Our voices have been heard as we’ve named – and given faces to – the problem. Now we need to be heard again, to help move Congress toward an acceptable solution.

This debate started out primarily as a partisan debate, not as a problem-solving exercise. Both parties need to be urged to go back to the table with a shared goal in mind – the health of (all of) the people who live in this country, and particularly the health of this country’s first residents. We can move Congress to hold open a space for respectful,compassionate, and practical solutions.