Health Care

The Senate Holds All the Cards on Health Care

Make no mistake about it: Something could very well pass.

War zone.

Photographer: Alex Wong/Getty Images

If it's true that the entire health care reform effort since January has been one large exercise in blame-shifting, then Paul Ryan and House Republicans have successfully -- for now -- shifted blame for the failure to repeal and replace Obamacare over to the Senate. With 20 Republican defections, but with many Republicans in tough districts still having to cast tough "yes" votes, the House passed the American Health Care Act by the razor thin margin of 217 to 213.

The bill as passed is, as the kids say, a hot mess, and it sure doesn't seem to have many enthusiastic supporters. They did manage to separately pass a bill to keep their bill from protecting members of Congress and their staff members from what they are doing. But they rushed it to the floor before getting a score from the Congressional Budget Office. That's not just about how it would affect the federal budget deficit; they also passed this thing without any careful analysis of what the bill-as-amended would actually do. The original version, pulled from the House floor back in March, would have reduced the number of insured Americans by an estimated 24 million; we don't know whether this version will do better or worse. Nor do we have any neutral estimates on how it would affect premiums or anything else.

We do know that the bill polls very badly, and it's unlikely that individual provisions poll well -- there's not a lot of support out there for cutting off funding for special education, for example. Or ending the ban on lifetime caps or protections for those with pre-existing conditions -- including for those with employer-linked insurance. This really differs from Obamacare, where most of the individual provisions were popular, but not the overall law. And recently, the Affordable Care Act itself has become popular, anyway, making the Republican repeal effort even more risky for them. 

The biggest questions now are about what will happen in the Senate. This is a "reconciliation" bill, which means it will be protected against filibusters and will need only a simple majority to pass. But it also means that only certain provisions (those that affect the federal budget) can be included. It's entirely unclear what the Senate parliamentarian -- an unelected official who singlehandedly makes major decisions on the reconciliation process -- will allow, and what Mitch McConnell and Senate Republicans will do if the parliamentarian turns what the House has done into Swiss cheese by stripping various provisions from it. 

Nor is it clear that 52 Senate Republicans (with the support of Vice President Mike Pence to break ties) are enough to pass anything. To begin with, it seems likely Maine's Susan Collins and Alaska's Lisa Murkowski will oppose anything that retains the House bill's hit on Planned Parenthood. Another half dozen or more Republican Senators have spoken against the measure's cuts to Medicaid. And then Kentucky's Rand Paul wanted a full Obamacare repeal, and it's possible a handful of others (Ted Cruz of Texas? Mike Lee of Utah?) might join him in opposing the House bill (let alone anything modified to get the votes of Collins and Murkowski) as too weak. 

It's absolutely possible that Senate Republicans can figure out a way forward, but it should be at least as hard for them to get their version of the bill over the finish line than it was for House Republicans to do so. It may be even harder at this stage of the process: Several members of the House said that they were counting on the Senate to modify things, but senators have less leeway to pass the buck in the same way.

Harder, but not impossible. If the Senate does pass something, and assuming the House isn't willing to just rubber-stamp that version, then the two chambers would have to hammer things out in a conference committee. And the math is still extremely daunting: House Freedom Conference radicals simply want a bill that doesn't appear to have 50 votes in the Senate.

That said: It is true that the Freedom Caucus showed some ability to compromise on this. They did an impressive job of moving the bill toward their position, but what almost all of them voted for today was still considerably short of what their ideal bill would have been. 

My guess is that it's still fairly unlikely that any version of this makes it into law. President Donald Trump is hosting a victory party at the White House for House Republicans today, and I still think their best strategy is to just pretend that they've killed off Obamacare for good, and then go on administering it. 

But make no mistake about it: Something could very well pass. Even if very few House or Senate Republicans are excited by their bill and are fully aware of the electoral risk some of them are taking, politicians like to do what they promised, and they -- as a group -- promised to repeal and replace Obamacare. Many of them also remain individually more worried about being defeated in primaries if they take the blame for failure than they are about being defeated in general elections because they are blamed for voting for something unpopular. Only the latter can cost Republicans their congressional majorities. They do care about those majorities, and some of them are worried about their own general election prospects. But in the short run, the most powerful factor may be blame-shifting, and it's still possible they could blame-shift this thing all the way to final passage and a signing ceremony. 

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

    To contact the author of this story:
    Jonathan Bernstein at jbernstein62@bloomberg.net

    To contact the editor responsible for this story:
    Mike Nizza at mnizza3@bloomberg.net

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