Senate Republicans are now reliving the House’s health care nightmare

Senate Majority Leader Mitch McConnellChip Somodevilla / Getty Images

After the unruliness of the House health care debate, which dragged out for months and resulted in an awkward, unsatisfying final product, the Senate sought a better way to fulfill the Republican campaign promise to repeal and replace Obamacare.

But three weeks into their negotiations, senators still sound stuck on many of the same issues that fractured Republicans in the lower chamber.

The raucous process in the House to pass the American Health Care Act put on full display the deep divisions within the Republican Party on how, exactly, to deliver on their long-held promise. The far right wanted to undo the law as much as they could; moderates were uncomfortable with the consequences, and projected coverage losses, that would follow.

The House found a compromise that squeaked through on a vote of 217 to 213, but the same drama promised to repeat in the Senate, where Republicans have a narrow margin for error. Even with a procedural shortcut, Senate Republican leaders can afford to lose only two of their 52 members. Depending on how you count, at least a dozen GOP senators have already expressed concerns about the House plan.

So leadership gathered its most conservative and most moderate members into a working group, with the belief that if this collection of senators could agree to a plan, then they would be assured of success. A few days a week since the beginning of May, those senators have been meeting in offices in the bowels of the Capitol.

The public comments out of those meetings have been positive, if a bit reserved: “It’s gonna come down to: We’re gonna have to do the job,” Sen. Orrin Hatch, one of the top senators working on the Senate plan, said.

But behind the scenes, despite the best intentions, the Senate is nevertheless running into the same problems that plagued the House. Conservatives want to move their health care plan even further to the right, rolling back more of Obamacare more quickly. Moderates are nervous about the repercussions.

Senior Senate Republicans are flirting with policies, like automatically enrolling uninsured Americans in some kind of health coverage, that are sacrilegious to their most conservative colleagues. At the same time, the latter group is pushing for steeper Medicaid cuts and a more aggressive rollback of Obamacare’s insurance regulations, a course that is sure to make moderates worried about coverage losses uncomfortable.

It took a humiliating public failure for the House to resolve its differences. Senate Republicans are now staring at a long summer of talks, with neither side sounding anxious to compromise and no promise that they can find a passable plan in the end.

The Senate working group puts the right and the middle in the same room

The original version of the American Health Care Act passed only after the archconservative Freedom Caucus and the centrist Tuesday Group found changes to the initial bill that worked for both of them.

As soon as the Senate’s working group was established and its membership announced, it was clear GOP leaders in the upper chamber hoped to skip the revolt and fast-forward to the compromise.

The group included Senate Majority Leader Mitch McConnell and his No. 2, Sen. John Cornyn; finance committee chair Hatch and health committee chair Sen. Lamar Alexander; some of the caucus’s most conservative members, Sens. Mike Lee and Ted Cruz, and some of its moderate senators, Rob Portman and Cory Gardner.

Leadership, committee chairs, moderates, and conservatives. Senate leaders were criticized from initially excluding any women from the group, but it was an ideologically diverse gang of 13.

“If this group can agree, they can pass a bill,” one Republican health care lobbyist, who used to work in the Senate, told me.

But they haven’t yet agreed — though for the most part, everybody is putting a good face on their progress. Still, the meetings are opaque. Senators say they aren’t supposed to disclose the details of what was discussed, and they’ve already made clear they won’t be going through the usual committee process — despite those years of protestations that Democrats passed the Affordable Care Act in the dead of night without any public debate.

McConnell saw how messy the House debate, as truncated as it was, became, and he’s likely trying to shield his members from the same circus. He was reportedly furious that some discussions had been leaked, according to Roll Call, and ordered most staff out of the room at a meeting last week.

“There are many ideas being discussed and rather than battle them out in the press … the conversations we’re having are productive. We’re seeing senators across the ideological spectrum working to try to get to yes,” Cruz told reporters recently. “That’s exactly the inclusive process that we have to employ if we’re going to get to a bill that commands the support of 50 senators.”

But Senate Republicans are still stuck on many of the same health care problems

Senators have emphasized that they’re writing their own health care bill, not simply coopting the House plan. One consequence of that seems to be that they are now rehashing all the same policy fights that the House endured.

The broad contours of the House plan never changed much. It transitions from Obamacare’s income-based subsidies for private insurance to subsidies based on age. It phases out the health care law’s Medicaid expansion and fundamentally overhauls the program’s financing, instituting a spending cap that is expected to reduce funding by $800 billion over 10 years.

But House conservatives were angry that Obamacare’s insurance rules largely remain and moderates were worried about the estimated 24 million more people who would be uninsured. After House leaders were forced to pull the bill from the floor in late March, those two wings found a compromise to get it passed. States would be allowed to opt out of Obamacare’s rules, with some conditions, and more funding was added to the bill to help cover people whose insurance might be at risk without those protections.

The House bill did help to narrow the parameters of the Senate’s debate. Instead of deciding whether to roll back Obamacare’s Medicaid expansion, the Senate is now at odds over how quickly to do it; the House bill set up a new system for financial aid to purchase private insurance, but senators have said repeatedly they want to change it to provide more help to low-income Americans.

But the battlegrounds feel very familiar.

Conservatives want to phase out the Medicaid expansion quickly and lower the cap on overall Medicaid spending even more than the House bill did. Moderates are looking for a slower phaseout and are uncomfortable with making the Medicaid spending cap any steeper than it already is.

Conservatives are pushing a plan that would repeal some of Obamacare’s central insurance reforms, such as the prohibition on insurers charging sick people more than healthy people, nationwide. Under the House bill, states would have to ask to waive those rules; Senate conservatives want to have states opt into the regulations. Moderates, like they were in the House, are wary of undermining the law’s protections for people with preexisting medical conditions.

How bad is it? Cruz suggested to reporters last week that the group hasn’t even agreed on a key debate about the tax credits people can use to buy private coverage. The Texas senator wouldn’t commit to making the credits advanceable, an essential feature if people are going to use to buy insurance rather than getting their money back months later. The House squabbled over this too, but resolved it early.

The sheer breadth of policies under discussion — automatically enrolling people in catastrophic insurance has been raised in the meetings — indicates how far the upper chamber likely is from consensus. They are now confronting sticky questions, such as whether they might have to keep Obamacare’s individual mandate or some of its taxes for a while in order to make their plan function.

In addition to the working group talks, Senate Republicans are discussing health care multiple times a week in their caucus lunches. The only test is whether a policy can get a bare majority.

“We’re not in a big hurry and let everybody participate, essentially a committee of the whole of the Republican conference,” Cornyn told reporters recently. “We’re gonna get to 51 senators. That’s really the ultimate goal.”

But that consensus feels ever further away. Some senior Republicans are even floatingpassing a short-term bill to stabilize the Obamacare markets, before returning later to a more comprehensive plan to repeal and replace the law.

And the sniping between the two wings is starting to spill out into the open.

Aides to more moderate senators are bewildered that some of their colleagues — particularly those, like Sen. Pat Toomey of Pennsylvania, who represent states that expanded Medicaid under Obamacare — want to make the Medicaid cuts even harsher. The House bill already cuts Medicaid spending by $840 billion over the next 10 years and reduces enrollment by 14 million people, according to the Congressional Budget Office’s analysis of an earlier version of the bill.

Meanwhile, aides to conservative senators are signaling their displeasure with the direction that senior Republicans want to take the Senate plan. One told me that they thought the committee chairs in the working group, Hatch and Alexander, wanted to keep the individual mandate for a few years and then transition into a system that automatically enrolls uninsured people into coverage unless they decided to opt out. Both concepts are anathema to limited-government conservatives.

Senate leadership’s strategy already seems at risk of failing

Senators and their aides have aggressively managed expectations from the start, saying it could take them months to develop their own plan. By that reckoning, we’re still early in the proceedings.

“They’re gradually making progress in discussing the matter. This is gonna take some time. There are a lot of different points of view, a lot of different conflicts here,” Hatch said recently. “We want to accommodate our colleagues and make sure every one of them feel like they’re a part of this.”

The Senate has also been hamstrung as they wait for a score of the final House bill from the Congressional Budget Office, which will finally come this week. That CBO score will give senators a better sense of how the House bill aligns with the complex procedural rules they are using to pass the bill and what budget baseline they have to meet as they rejigger the House bill’s spending and revenues.

It’s hard to make detailed policy decisions without that information. Nevertheless, senators insist they’ve been making progress — even if they’re never willing to divulge how exactly productive their discussions have been.

“They’re very in depth and they’re very specific and there are many good ideas and we have a lot of well-informed senators now on health care,” Alexander told reporters last week.

But you can see early signs of fissures that could drag the bill down. The policy divisions remain vast. And senators who were initially left out of the working group are venturing out on their own.

Senate leaders have grown fond of saying, especially after the criticism that they included no women in the initial group, that they have a group of 52 Republicans working on the plan and talking about it during the weekly lunches that bring the whole conference together at the Capitol.

But even so, rival workings groups have popped up.

The co-sponsors of a totally separate health care bill crafted by Sens. Susan Collins and Bill Cassidy — which would effectively allow states to choose whether or not they want to keep Obamacare — have met periodically over the last few months. Another group of senators representing Medicaid expansion states, led by Portman, has met on their own. A handful of Republican senators not included in the leadership-sanctioned group have held preliminary meetings with some Democratic senators, testing the waters for a bipartisan health care solution.

Those GOP senators on the outside looking in have become more and more pointed in their criticism of the leadership’s approach.

“The committee (that) Republican leadership has convened is going to produce a partisan bill,” Collins told the Portland Press Herald last week. “I disagreed when President Obama produced a partisan bill (the ACA in 2009). That’s not the best way for Republicans to legislate now.”

Perhaps wary of letting the conversation spin out of control, Senate leaders have invited every member of the conference to join those noon meetings of the health care working group. Hatch told reporters that 15 to 20 senators had attended one of the meetings last week.

“I’m gonna give it a shot,” Cassidy, one of the most outspoken Senate Republicans on health care who wasn’t initially included in the group, quipped as he entered a meeting last week.

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