Health care bill faces steeper climb in Senate
WASHINGTON — The Republican effort to reshape the nation's health care system cleared one major hurdle — and now it faces an even taller one.
House Republicans narrowly passed a controversial bill to repeal and replace key parts of the Affordable Care Act Thursday, and the legislation moves over to the Senate, where Republican leaders will have their hands full with political and procedural challenges complicating the chances for final passage.
Republicans hold a 52-48 advantage over Democrats in the upper chamber, leaving GOP leaders with a narrower margin for error than in the House — a chamber where infighting among Republican lawmakers nearly derailed the push on multiple occasions.
“When they send it over here, it'll be a real big challenge on the Senate side as well, and you'll have an opportunity to file lots of stories about the discussions as we move toward trying to achieve that,” Senate Majority Leader Mitch McConnell, a Kentucky Republican, told reporters this week.
The House bill is expected to undergo major changes in the Senate, where it will be subject to unlimited amendments and could be introduced in a different form than it has taken in the lower chamber.
Senate Republicans have opted to use a maneuver known as reconciliation to try to pass the bill with a simple majority, instead of having to clear the 60-vote threshold that is required for most legislation and in the current balance of power would require Democratic votes. But even getting to a simple majority will be no small task in a chamber where there are stark differences of opinion even among Republicans.
GOP senators from states that have expanded Medicaid under the Affordable Care Act, such as Sen. Rob Portman, Ohio, and Shelley Moore Capito, West Virginia, have voiced concerns about rollbacks to that program in the House bill. They are expected to address those worries during any debate over health care.
Meanwhile, a trio of conservative senators — Ted Cruz, Texas, Mike Lee, Utah, and Rand Paul, Kentucky — are also wild cards. They have been willing to buck party leadership; earlier this year, they pushed for a more aggressive repeal of the health care law than many of their colleagues favored.
Republican Sens. Bill Cassidy, Louisiana, and Susan Collins, Maine, have already introduced an alternative plan, giving lawmakers a second measure to look at should talks fall apart over the current bill.
Then there are the procedural hoops that Senate Republicans would need to clear. Democrats argue that could be difficult.
“Even if the new version of Trumpcare passes the House — and we hope that it does not — its chances for survival in the Senate are small,” said Senate Democrat leader Charles Schumer, New York, who like many Democrats is trying to link the bill closely with President Trump. “We don't even know if the new version would survive under the rules of reconciliation.”
The House measure's original version, introduced in March by Speaker Paul Ryan, a Wisconsin Republican, already contained elements at risk of being struck out in the Senate under budget reconciliation rules that allow tax and spending changes but not broader policy changes.
That original proposal initially left many of the ACA's insurance regulations alone — with the goal of ensuring it would pass muster with the Senate parliamentarian, a nonpartisan officer of the Senate who decides on what may go in a reconciliation bill — but not all of them.
The version of the bill the House passed Thursday undercuts the ACA's insurance regulations even more, by giving states a path to opt out of federal requirements for insurers to cover certain “essential” health benefits — and to allow them to charge sick people the same premiums as healthy people.
The GOP bill allows insurers to charge older Americans five times what they charge younger people, as opposed to three times as much under current law. And it enables insurers to hike premiums by 30 percent for people who don't remain continuously covered. Health policy experts, including conservative ones, have noted that the parliamentarian may decide those provisions need to be stripped out.
Additionally, members of the House voted on the bill before receiving a score from the nonpartisan Congressional Budget Office, which measures how much the legislation costs and how many people stand to lose coverage under it. Senate budget rules that require a CBO score that proves the legislation will not increase the deficit after 10 years.
The CBO projected in late March that an earlier version of the GOP health care plan would result in 14 million more people being uninsured in 2018 than under current law. It projected the plan would slash the federal deficit by $150 billion between 2017 and 2026.
Even if Senate Republicans manage to pass their own version of a health care overhaul, it would then have to be reconciled with the House version. And if getting House conservatives and moderates to pass their initial measure was a challenge, it could be next to impossible to get enough of them to sign on to whatever the Senate decided to pass.
“If they revise it, there's no way,” Rep. David Brat, R-Va., said earlier this week. Brat was one of the members of the hard-right House Freedom Caucus who refused to support the Ryan bill until provisions was added for states to opt out of more insurance regulations.
“Have you been watching for the last few months how tight this is, and you're going to shift this one or the other?” Brat said. “Good luck, you don't have to be Einstein to game theory that one.”