The U.S. Senate, with the support of Sen. Shelley Moore Capito, will likely vote to repeal the Affordable Care Act this week, despite Capito expressing misgivings last month at what a repeal might mean for West Virginians who have gained access to Medicaid through the law.
The Senate vote could come as soon today, following five years and dozens of unsuccessful repeal attempts in the House of Representatives.
That doesn't mean the health care reform law is going anywhere. President Barack Obama vowed Wednesday to veto the legislation, saying the repeal would "take away critical benefits and health care coverage from hard-working middle-class families."
To override a presidential veto, and make the repeal effort something more than political posturing, would take at least 13 votes from Democratic senators, an unlikely prospect.
Sen. Joe Manchin, probably the Senate's most conservative Democrat, will not be one of those votes.
"Sen. Manchin does not support repealing the Affordable Care Act," Manchin spokesman Jonathan Kott said Wednesday. "Sen. Manchin has always advocated making common-sense improvements to the law."
Last month, after the House approved its partial repeal of the health care law, the Republican junior senator indicated that she would be hesitant to follow suit.
"I am very concerned about the 160,000 people who had Medicaid expansion in my state," Capito, who has voted dozens of times to repeal the law, told The Hill, a Washington political newspaper. "I have difficulty with that being included."
The number of West Virginians who have gained health coverage through the Affordable Care Act's Medicaid expansion has since risen to more than 171,000.
But Capito's concerns have been assuaged. She urged repeal of the law during a speech on the Senate floor Tuesday.
(This repeal is likely to pass when others have failed because Republicans now control the Senate and because it's being proposed as part of a "budget reconciliation" process that allows it to bypass a Democratic filibuster and pass the Senate with 51 votes, rather than 60.)
The bill the Senate will vote on repeals major pieces of the Affordable Care Act, including the Medicaid expansion, but with a two-year delay for a transition to a currently undefined replacement plan.
"Sen. Capito expressed her concerns with the impact of immediately repealing the Medicaid expansion. This bill addresses those concerns," Capito spokeswoman Ashley Berrang said. "During this time, Congress and the next president could enact alternative reforms that provide access to quality, affordable health care."
Berrang said medical liability reform, tax credits and selling insurance across state lines should be part of a replacement plan.
Terri Giles, the director of West Virginians for Affordable Health Care, a group that supports the law, noted that "repeal and replace" is a familiar mantra but that she has yet to see a viable Republican replacement proposal.
"We've been hearing the same story for what, five years now?" Giles said. "It's like Sasquatch - somebody says 'I saw a replacement,' but there's no evidence of what it would be."
In her speech in the Senate on Tuesday, Capito called the health care law "a costly disaster" and mentioned "the thousands of West Virginians from my state who have lost or had to change their coverage."
Many more West Virginians have health coverage now than they did before the implementation of the Affordable Care Act.
The state's rate of uninsured people dropped by more than 38 percent from 2013 to 2014, a recent U.S. Census report found. That equates to about 99,000 people gaining insurance who didn't have it previously.
An August Gallup poll that compared the uninsured rate in 2013 to the first half of 2015 found an even bigger drop, with more than 52 percent of West Virginia's uninsured gaining insurance.
At the same time, West Virginia's insurance exchange - where people who don't get insurance through Medicaid, Medicare or their employer can buy insurance - is struggling.
Only 40 percent of West Virginians think the law is effective at providing health care, an August poll found.
West Virginia remains the only state that has only one insurer offering plans on the exchange.
Fred Earley, the president of that insurer, Highmark West Virginia, said the exchange is challenging for his business.
The people buying insurance on the exchange are using that insurance - through doctor visits, hospital stays, or whatever - a lot more than customers in Highmark's other insurance pools, Earley said. That means the company has to pay out more than it expected (more than it is taking in in premiums) and is losing money on the plans it sells through the exchange.
"It's still a very challenging population, moving forward," Earley said. "We need to get it to a point where it is able to support itself and not be subsidized by other pools of business."
Earley said the company is making plans to be in the exchange next year, as well, but that decision relies on factors he can't yet predict.
Highmark has raised premiums on its plans more than 20 percent, on average, this year in West Virginia, a rate significantly higher than the national average.
Most people buying insurance on the exchange - and there were about 31,000 last year - won't notice the rate increases. That's because their income is low enough that they receive federal subsidies to cover the cost of insurance beyond what is deemed "affordable."
(The window to buy insurance on the exchange started Nov. 1 and runs through Jan. 31, 2016.)
Last year, 86 percent of people who got insurance on the exchange received subsidies, according to the U.S. Department of Health and Human Services.
But that still leaves about 4,300 people who buy unsubsidized insurance, plus untold more who go without insurance and are subject to a tax penalty.
Those are people like Giles, who said she pays nearly $550 a month for a mid-level "silver" insurance plan, and still has to pay for doctor visits.
Giles called the repeal plan nothing but a political game and said Congress is neglecting serious problems with the law that it could fix.
"Many people who are in the middle class, they're really struggling on it," Giles said. "Clearly, people who were uninsured are indisputably better off. If repeal comes to pass, I've got 170,000 people that are going to be hurting really badly in our state."
Reach David Gutman at david.gutman@wvgazettemail.com, 304-348-5119 or follow @davidlgutman on Twitter.