Health Care

What's Next for the Republican Health-Care Bill

Mitch McConnell, take heart: It's not dead yet.

Something's still missing.

Photographer: Aaron P. Bernstein/Bloomberg

How did Mitch McConnell finally come up with the votes -- 50 of the 52 Republicans plus the vice president to break the tie -- to begin Senate debate and the amendments process on a Republican health-care bill?

While it's hard to prove anything, Tuesday's big vote, like everything else that's happened so far since January, is consistent with the view that most Republicans in Congress believe this ends in failure, and (almost) all of them are scrambling to shift blame elsewhere. Which means it's still quite possible that they'll almost accidentally blame-shift their way into passing something none of them really want to see as law. 

Of course, McConnell still needs a bill.

Right now, the Senate is considering amendments, including full substitutes for the House-passed bill they are working from. But this is all mainly for show and to send messages. What will really matter is the final amendment to the sequence, which is tentatively scheduled to come to a vote on Friday. That will be the one that McConnell thinks can pass the Senate, which is apparently some version of a "skinny repeal," which would eliminate Affordable Care Act mandates and some taxes but leave certain Medicaid and Obamacare regulations and subsidies in place. Under the procedure they are working under, if it passes, it will wipe out everything else they have done to that point. If it doesn't pass, then McConnell has nothing for the Senate to vote on, so they'll have to either give up or try again.

So while the amendment votes might give McConnell some clues about what will and won't pass -- and might give operatives on both sides material for campaign ads next year -- the real action is McConnell's efforts to find something that can win the support of 50 Republicans. There, the math remains the same: About 35 of the 52 Republicans will apparently vote for anything; a dozen or so senators are worried about cuts that might hurt their constituents directly or harm them in a general election; and three or four extreme conservatives oppose anything that institutionalizes government involvement in guaranteeing health insurance for everyone. Since they can only lose two Republican votes, that's no easy task.

Or, to put it another way: The "skinny repeal" bill might make Rand Paul, Ted Cruz, Mike Lee and Ron Johnson happy because it would remove an important piece of Obamacare -- the individual mandate -- without replacing it with something they would consider a big government intervention, even though it will be nowhere close to full repeal of the Affordable Care Act. However, removing the mandate may well collapse the individual market for health insurance. Many other senators don't want to vote for something that would have that effect, and it will likely push McConnell to include some mechanism intended to replace the mandate -- but in doing so, McConnell might lose the votes of Paul, Cruz, Lee and Johnson. And if Maine's Susan Collins and Alaska's Lisa Murkowski, both of whom voted against the motion to proceed, wind up lost to McConnell anyway, then he can't lose anyone else.

McConnell will presumably attempt to sell a vote on a Senate version of a bill the same way he sold the "motion to proceed" vote: as the only way to keep the process moving forward. That may work. After all, it worked on Tuesday. But senators will probably believe a vote on passing a specific bill will be a more risky vote than one to consider amendments. 

The Senate won't be the final step. We know that anything that passes in the Senate will be at least somewhat (and probably very) different from the bill that narrowly passed the House. That leaves three options. The House could simply vote on the Senate-passed version, and if it passes, it will go to the president for his signature. That's still the most likely next step, but it's not at all clear the House will support anything the Senate passes. 1 It's also possible that House leadership (perhaps in consultation with Senate leadership) could modify or even entirely rewrite the bill coming out of the Senate, then take a vote on that new version. Under that "ping-pong" procedure, the bill would move back and forth between chambers until the same exact version passes in both; at the very least, this would mean both the House and Senate would have at least one more vote after initial Senate passage.

The third, and by far least likely, option would be a formal conference committee in which members of the House and Senate meet to settle their differences. That used to be how normal legislating happened, but it's fallen out of favor recently regardless of which party holds majorities, and nothing about the secrecy with which Paul Ryan and Mitch McConnell have chosen so far suggests that they would risk the public wrangling of a conference committee. If they do, the bill agreed to in conference would still need approval by both House and Senate.

All we really learned from the Senate motion-to-proceed vote was that at least 50 of the 52 Republicans weren't willing to let the process end at this point; it's a very different action to vote for a specific bill. The bill right now is probably the least dead it's been in some time. It's hardly healthy, however. We won't know for a while whether the bill is Not Dead Yet and recovers, or is like the princess's father, who "when he seemed about to recover, suddenly felt the icy hand of death upon him." And yes, it doesn't help the bill that far more people outside Congress want it to be entirely and completely dead. 

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

  1. We can assume, however, that Donald Trump will sign anything put on his desk, since he's said so and has offered no conditions or even consistent suggestions for what should be in the bill.

To contact the author of this story:
Jonathan Bernstein at

To contact the editor responsible for this story:
Brooke Sample at

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