As Mitch McConnell struggles to come up with a health-care bill that can command 50 Senate Republican votes, what was once a tight focus on a few narrowly defined trade-offs between “conservatives” and “moderates” is getting a bit out of control. GOP senators are suddenly questioning the quiet ideological driver of the whole process, big tax cuts for the rich. A key conservative, Ted Cruz, is suddenly promoting a major change in the bill that would let insurers who offer one Obamacare-compliant health plan also offer skimpier plans that would be magnets for younger and healthier people. It’s still unclear whether McConnell can get across the finish line, but what’s new is the possibility that a successful bill could look quite a bit different from what was on the table just a couple of days ago.
That could be disorienting not just for the various interested observers of this process — like, say, conservative advocacy groups and health-industry lobbyists — who thought they had a fix on the bill, but for the most interested observers of all: the House Republicans who so narrowly passed their version of this legislation just under two months ago.
The original BCRA was very similar to AHCA, despite a lot of earlier senatorial talk about “starting all over” without much reference to the House’s handiwork. The transparent reason for this similarity was McConnell’s hope that he could convince the House to rubber-stamp the Senate bill, avoiding the time-consuming and politically perilous process of a House-Senate conference committee followed by a conference report that would face another vote in each chamber. The more BCRA drifts away from AHCA, the less likely that smooth and rapid scenario becomes.
It is possible, I suppose, that in addition to the juggling he’s doing with senators, McConnell has been talking to Paul Ryan every hour, and is reasonably sure the two chambers can maintain a high level of harmony. It is also possible, in theory, that the Senate will produce a bill that is so much more popular than AHCA that House members will gleefully embrace it even if it abandons key House provisions — including deals made in the House to get AHCA over the top. One positive sign is that House Freedom Caucus chairman Mark Meadows has indicated he’s open to the kinds of changes senators are discussing (including fewer tax cuts), and is still inclined to avoid a House-Senate conference.
But there’s a long road to that sort of outcome. For one thing, whatever the senators agree to — if anything — will have to be rescored by CBO, and will have to pass muster with the Senate parliamentarian (which could be very difficult with respect to the regulatory changes Cruz is talking about). At this critical point, McConnell probably is not thinking much about the House at all. If he does get a bill out of the Senate, he and Ryan and the erratic man in the White House may need to sit down for a long talk about how to get from here to a signing ceremony.