Analysis: Republicans are just starting the hard part on health care
If repealing Obamacare was a marathon, Republicans have only made it past the first few mile markers. They face a long, steep road ahead in the Senate, filled with procedural and political potholes that could derail them at every turn.
WASHINGTON — If repealing Obamacare was a marathon, Republicans have only made it past the first few mile markers. They face a long, steep road ahead in the Senate, filled with procedural and political potholes that could derail them at every turn.
It was exhausting to follow the daily twists and turns as the House GOP struggled over the past two months to pass their measure overhauling big parts of the Affordable Care Act. So it's hard to believe that was the easy part — yet it was. The heavy lift's in the Senate, where Republicans face an even narrower path to success (they can only lose two of their own in a chamber with 52 Republicans and 48 Democrats) and where they must squeeze health policy into the narrow confines of a budget bill.
Think of the eventual Senate bill as a close sibling of the House bill — but certainly not its twin. Thirteen Republicans, selected by Majority Leader Mitch McConnell (R., Ky.) are working on legislation that may look quite different from the House measure once all's said and done. And that's assuming they're even able to come up with a bill that could both get approved by the Senate parliamentarian and attract the 50 votes needed to pass it.
The group is meeting Tuesday to discuss Medicaid changes. Still, most Senate-watchers agree none of this will happen very quickly, so we're gearing up for a long, but not lazy, summer. McConnell has been silent on a timeline, but fired off some angry Obamacare tweets this week.
Pages could be written on all the challenges stacked up against Senate Republicans trying to ditch the current law.
But for you, readers, here are five dynamics to watch that will determine if the Senate can get to the 51 votes needed to pass its form of health care:
1. Moderate senators will insist on reversing some of the Medicaid spending cuts.
Republican senators from Alaska, West Virginia, Maine and Ohio have already objected to how the Republican health-care bill would cap Medicaid spending, writing in a March letter to McConnell that it doesn't include "stability" for people who were newly eligible for the program in the last few years.
The letter was signed by Sens. Lisa Murkowski, Shelley Moore Capito, Susan Collins and Rob Portman, who are all under heavy pressure to ensure coverage gains under the Affordable Care Act aren't rolled back.
But restoring some of the Medicaid spending could jeopardize an aspect of the bill that is a winner for Republicans — its estimated $150 billion in savings over a decade. And it could alienate conservatives, who are under pressure from groups like Heritage and Americans for Prosperity to slash federal programs.
2. About 20 Republican senators live in states with Medicaid expansion, including two in tight races next year.
Besides capping overall Medicaid spending, the GOP plan would also slash extra federal funding for states that expanded their programs under the Affordable Care Act. That has a number of Republicans wary, most notably Sens. Jeff Flake of Arizona and Dean Heller of Nevada, both facing tough reelections next year.
Of course, the fact that Flake and Heller are the only two truly vulnerable Republicans up in 2018 could also bode well for efforts to roll back Medicaid, as Republicans weigh the immediacy of their political risks.
3. The most likely GOP defectors from the House bill are: Sens. Collins, Maine, and Murkowski, Alaska, (moderates) and Sen. Rand Paul, Ky., (libertarian/conservative). Republicans can lose only one of these three lawmakers and still pass health care.
Besides protesting the bill's Medicaid cuts, Collins and Murkowski have also said they dislike how it would slash funds to Planned Parenthood for one year. Notably, neither of them are in the 13-member working group.
If McConnell loses both their votes, he'd have to win over every single other Republican — including Paul, the most likely conservative to defect from the House bill. Removing Planned Parenthood defunding from the bill is one way McConnell could win over Collins and Murkowski, were he to lose Paul.
4. Conservatives will try to pull the bill toward a fuller Obamacare repeal.
Speaking of Rand Paul, he was the most vocal senator to ally with the House Freedom Caucus while its members were demanding that the GOP health plan repeal more of the law's insurance regulation — indicating he's ready to cause a ruckus in the Senate, too.
Paul, along with Sens. Ted Cruz, Texas, and Mike Lee, Utah, could dramatically complicate things for Senate leadership by insisting on further steps in that direction. To move the bill in a more conservative direction, they could also try to switch its refundable tax credits to nonrefundable tax credits or cut off the federal funding for Medicaid expansion enrollees sooner. Both Cruz and Lee will have input in the Senate bill, as they're among the Gang of 13.
5. And then there's the Senate parliamentarian.
Trying to repeal even more of Obamacare's insurance regulations could backfire. As it is, the House health bill already contains some elements that very well may be stripped out by the Senate parliamentarian because they don't affect spending directly, as is required under the special budget rules that allow Republicans to seek the magic 51 and not 60-vote number.
In other words, the Senate may not even be able to tackle the House bill if the parliamentarian decides much of it doesn't meet what's known as "Byrd rule" standards. This is the first hurdle the bill must tackle and it could result in major parts getting stripped out, or even death to the entire bill.