Montana's senators split on the motion Tuesday to begin debate on a health care bill that would do away with the Affordable Care Act, and split again on the first vote on the senate's version of the health care bill.

While Democratic Sen. Jon Tester's opposition was not a surprise, the "yes" vote from Daines was the first time he had taken a stance on the Senate's Better Care Reconciliation Act.

Daines called the first vote Tuesday a step forward in a long-promised repeal of something his party has opposed for years, while Tester said the day was one of his worst in the Senate.

"I just don’t think this is a great day in Montana, and it’s certainly not making America great again,” Tester said after voting against the motion. Tester was referencing President Donald Trump’s campaign slogan, Make America Great Again.

Trump and Republicans around the country ran on repealing and replacing the Affordable Care Act, former Democratic President Barack Obama’s signature health care law sometimes called Obamacare.

Daines said his vote to move forward fulfills a campaign promise he’s made going back seven years.

“This is an important first step,” he said. “Montanans have said we do not want to see Washington, D.C., solutions. We want to see Montanans back in charge of their health care and that’s what we’re going to be debating here.”

Senators will be picking up the House version of the bill, which will be debated and see many amendments. There will be a vote on one of three options — a repeal, a repeal and replacement, or a “skinny repeal” option that abolishes just some mandates of the Affordable Care Act. The House could then pass the Senate’s version of the bill or have a conference committee with the Senate to resolve differences; then each body would vote on the bill again.

Tester called Tuesday’s first vote “totally irresponsible” and said it will severely and negatively affect rural health care. He doesn’t believe any efforts by the Senate to amend the bill will make it more palatable.

“It’s going to hurt rural hospitals, it’s going to make health care more expensive. There’s no replacement plan out there that will work. Everything that has been brought up in the Senate is a total train wreck. What we did has the forefathers rolling over.”

A report prepared by Manatt Health for the Montana Health Care Foundation estimated the House and Senate versions of the bill would all have a huge impact on rural health care by increasing costs to buy coverage in those parts of the state and eliminating Medicaid expansion, which has covered many in rural areas and generally lowered the amount of charity care rural hospitals provide.

“Rural hospitals have told me it could potentially close their facilities or definitely change the way they deliver health care,” Tester said. “It’s not good for rural America. It’s about as irresponsible as anything I’ve ever seen.”

Daines reiterated what he’s said before: he believes Obamacare is broken and something has to be done. He cited increases in premiums and people losing access to their existing health care plans and access to doctors as reasons he considers the law failed.

Tester said he and Daines talked some time ago about pre-existing conditions and lifetime caps and “making sure we didn't’ do silly stuff with Medicaid that would hurt Montanans.”

“He just doesn’t see eye to eye with me on these issues, I think it’s fair to say,” Tester said.

Daines has long opposed Medicaid expansion, which has provided coverage to nearly 80,000 working poor in the state. He wants the program to return to covering only children, people with disabilities, pregnant women and others who are medically needy. 

Montana voted to expand coverage to the working poor and nearly 80,000 have signed up since 2016. But the law sunsets without legislative approval in 2019, and under both the House and Senate versions of replacement bills the amount of federal funding for the program drops so severely the state could not continue it.

“It’s on an unsustainable path,” Daines said. “Is it fair for the federal government to pay 100 percent for able-bodied people? That’s a fundamental fairness question.”

The Republican senator said he would support switching Medicaid to being administered by states through block grants or per-capita funding, something Democrats say will ultimately reduce the amount of money available and bring on cuts in the program.

Tester has been an outspoken opponent of any effort to repeal or replace the Affordable Care Act, but has called for strategic improvements, something he says isn't possible under the current situation.

“Take a look at the bills that were put up,” Tester said. As for possible changes to come on the Senate floor, he said “it does not matter what amendments we put on. In the end it’s going to be a bill that’s going to do what they all were going to do: give tax breaks to the rich, block-grant Medicaid, eliminate Medicaid expansion, not take care of the folks that hit lifetime caps.”

Daines had not taken a stance on any bill before Tuesday's vote, but said to get his support legislation would have to lower premiums, lower the cost of health care, cover those with pre-existing conditions and protect Medicaid for those traditionally covered.

To lower costs, he advocated for a proposal that would allow insurance companies to sell policies that do not meet all the mandates of the Affordable Care Act, arguing a young person may need a less expensive plan that offers less coverage than a 60-year-old.

Daines also said he will offer an amendment on the Senate floor that would require the government to reimburse everyone who paid a fine for not having health insurance, something that was mandated by the Affordable Care Act.

When asked how he and Tester can have such opposite views of the bill, Daines offered the state’s support of Trump as reason his views aligned more closely with Montanans.

“Montana overwhelmingly voted for President Trump, and President Trump campaigned strongly on the promise of repealing and replacing Obamacare. The American people have spoken loud and clear. Montanans have spoken loud and clear, electing Donald Trump by more than 20 points last year."

Tester, meanwhile, said he's struggling to see how actions Tuesday could mean anything but trouble for Montanans.

“This is one of the lower-level days I’ve had in the U.S. Senate. You can’t make this bill work for rural America. It’s all about removing access and affordability, which is just the opposite direction we should be going in, especially for rural areas that have facilities that are at real risk of closing.”

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