The next step in repealing and replacing Obamacare promises to be a long, slow slog with enough political obstacles to tie it up for months, if not years.
Republicans hold a more narrow majority of 52 to 48 in the Senate. And divisions within the GOP there are just as stark as the differences between its factions in the House of Representatives that stymied the bill’s progress in that chamber.
It’s unclear what provisions will need only 51 votes to pass and which will need 60.
There’s the culture of the Senate, which prides itself on taking a cautious, deliberative approach to legislation. For starters, the Senate will wait on a score, or fiscal analysis, from the Congressional Budget Office before it begins its review.
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And it will write its own bill. Thirteen Republican senators – including Majority Leader Mitch McConnell of Kentucky, Finance Committee Chairman Orrin Hatch of Utah, Budget Committee Chairman Mike Enzi of Wyoming and Health Committee Chairman Lamar Alexander of Tennessee – have been named to a working group to develop a Senate version.
The rest of the committee is Majority Whip John Cornyn of Texas, John Thune of South Dakota, Ted Cruz of Texas, Mike Lee of Utah, Tom Cotton of Arkansas, Cory Gardner of Colorado, John Barrasso of Wyoming, Rob Portman of Ohio and Pat Toomey of Pennsylvania.
“It’ll be a real big challenge on the Senate side,” McConnell acknowledged to reporters before the House cleared its version, even as he said the Senate could deliver a win without Democratic cooperation.
“Congress will continue to act on legislation to provide more choices and freedom in health care decisions,” McConnell said after the House narrowly passed the bill, by 217-213. “The pain caused by Obamacare is real for millions of Americans. We must repeal and replace this failed law.”
There are already competing Republican health care plans in the Senate that reflect the split. A more moderate version was introduced earlier this year with the hope of garnering Democratic support, but it does not repeal the taxes in the 2010 law that pay for many of the provisions in Obamacare.
The plan offered by Sens. Bill Cassidy, R-La., and Susan Collins, R-Maine, also allows states that want to keep the Affordable Care Act to do so. Neither is part of the working group, but might play a central role in negotiations.
We don’t want to give up on this. It’s no secret that this has been a big issue in the last four campaigns and we’re going to continue to work on it.
Senate Majority Leader Mitch McConnell, R-Ky.
The pair’s bill failed to attract conservatives like Sen. Rand Paul, R-Ky., who has his own Obamacare Replacement Act, which would eliminate the requirement that most Americans purchase insurance or pay a fine and would authorize tax credits for individuals and families that contribute to health savings accounts. Paul, who is also not in the working group, said House conservatives had made the initial version of the legislation “less bad” but that he still had “fundamental problems” with the House bill.
“When you only have 52 senators who will vote for it, that means you’ve got to get everybody to a point where they can agree with the final product, so it will be collaborative,” Cassidy said.
Cassidy offered a new standard for the legislation: “the Jimmy Kimmel test,” a nod to the late-night talk show host who delivered a passionate plea on health care after his newborn son underwent surgery.
“I ask, ‘Does it pass the Jimmy Kimmel test?’ ” Cassidy told CNN on Friday. “Would the child born with a congenital heart disease be able to get everything she or he would need in that first year of life . . . even if they go over a certain amount?”
He dismissed worries that the Senate will moderate the bill so much that it will lose the conservative House Freedom Caucus, which championed efforts to push the legislation to the right.
“I think the president has shown himself quite persuasive,” Collins said of President Donald Trump, who invited House Republicans to the White House for a victory party in the Rose Garden after the vote. “I would expect that to continue.”
Cassidy also dismissed the conventional wisdom that the lift would be too great for the Senate: “People were saying the same thing about the House,” he said.
At the White House, Trump said he was confident the bill would pass the Senate: “It’s going to be an unbelievable victory, actually, when we get it through the Senate,” he said. “And there is so much spirit there.”
But the legislation could look very different. Senate Health Committee Chairman Alexander congratulated the House on its bill Thursday but said the Senate would finish its own version and would “take the time to get it right.”
Alexander said his priorities included giving states flexibility with Medicaid, “but doing this in a way that does not pull the rug out from under people who rely on Medicaid.”
Republicans from states that have expanded Medicaid coverage under the 2010 law have already worried publicly that the House plan does not “provide stability” for families in Medicaid expansion programs, which would be phased out under the measure. Gardner, Portman and Sens. Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia sent a letter to McConnell in March outlining their concerns.
They tell us they’re so smart and they’re so good at this stuff and we’re so incapable that they need to work on it, and I agree with them they need to work on it.
Rep. Michael Burgess, R-Texas
Senators continued Thursday to voice reservations about the House’s dash to approve legislation.
A bill that hasn’t yet been reviewed by the Congressional Budget Office and passed with only three hours of debate “should be viewed with caution,” Sen. Lindsey Graham, R-S.C., said in a tweet.
Senate Minority Leader Chuck Schumer, D.-N.Y., pegged the legislation’s chances for survival in the Senate as small. It’s still unclear, he said, whether it will pass the chamber’s rules for reconciliation, which make legislation easier to pass without bipartisan support.
Republicans want to fast-track the bill under a special parliamentary rule that allows it to pass with a simple majority vote. But the rule prevents anything that doesn’t directly change spending or revenue levels from being passed under reconciliation.
Schumer said he thought the amendment in the legislation that would allow states to drop the requirement that pre-existing conditions be covered would violate the provision, known as the Byrd rule.
“The reality is Trumpcare cannot pass the Senate,” Schumer said on the Senate floor. “To my moderate Republican colleagues in the House, I ask: Why would you risk a yes vote for a bill that is devastating to your constituents and has a minuscule chance, probably no chance, of becoming law?”
After grappling with debate over the bill in Congress and at home, some House members said they were eager for the Senate to take up the matter.
“They tell us they’re so smart and they’re so good at this stuff and we’re so incapable that they need to work on it, and I agree with them they need to work on it,” said Rep. Michael Burgess, R-Texas. “I want them to. I’m anxious to see what they are going to do with finishing the job that we started.”
His fellow Texas Republican, Rep. Joe Barton, said it was inevitable the bill would have a harder time in the Senate.
“If I sent a resolution saying the sun rises in the East, some senator from the West would say, ‘We’re not so sure about that,’ ” Barton said. “Let’s get it out of the House first. Let’s get something out of the Senate. Let’s get a conference report. We’re going to get there. It’s going to be messy, but we’re going to get there.”
Indeed, Republicans in the Senate view the legislation “with a mixture of hope and dread,” said Rep. Tom Cole, R-Okla.
“Some of our colleagues over there have been rolling hand grenades across the Rotunda since this began,” Cole said. “I would hope because they want to caution us to do the right thing, but also some of them, I think, just never wanted to take it up.”
It could take the Senate three or four weeks to take up the bill, Cole said. That’s partly because the chamber will wait first for a score from the Congressional Budget Office, which would reveal the impacts of the legislation.
Democrats predicted the bill will stall as the Senate tries to assuage members’ worries.
“McConnell’s probably pulling his hair out because he doesn’t want to have to deal with this,” said Rep. Emanuel Cleaver, D-Mo. “When they send it back here, the Freedom Caucus will bail. You’re back to square one.”
Rep. Mark Meadows, R-N.C., who chairs the conservative Freedom Caucus, which has sought to pull the bill to the right, said he’d already talked to more than a dozen senators about the bill, including Cassidy, who presented his legislation to the Freedom Caucus.
“The bill will change in the Senate; I believe it will get better,” Meadows said, adding that House and Senate members have already talked about reaching an agreement “in very quick order.”
Still, House members know the hill yet to climb, and they showed it during the victory speeches Thursday in the Rose Garden.
“I know that our friends over in the Senate are eager to get to work,” said House Speaker Paul Ryan, R-Wis. Behind him onstage, Republican House members laughed.
Alex Daugherty, Franco Ordoñez, Curtis Tate and Lindsay Wise contributed to this report.