Understanding how Senate deliberations over the GOP’s plans to repeal and partially replace Obamacare will differ from the House requires a sort of 180-degree rotation in perspective, with three key factors.
First, it’s important to understand that the popular idea that the House bill now “goes” to the Senate for a vote is just wrong. The Senate may eventually choose to include components of the House bill in its own bill, for its own reasons or to make it easier for a House-Senate conference committee to reach agreement and for the House to approve it. But the House bill has no real status in the Senate, which will mark up separate legislation through its own committees of jurisdiction. Here’s how that will change the debate:
1. Budget rules are now very real. In the House, talk about what might or might not survive Senate budget rules was merely theoretical. Now, after the Congressional Budget Office “scores” the House bill, the Senate parliamentarian will decide which elements do and don’t comply with the chamber’s unique rules of germaneness and deficit-neutrality when dealing with budget-reconciliation bills, which is technically what “Trumpcare” is (reconciliation is a procedure adopted by Republicans in both Houses to avoid the possibility of a Democratic filibuster). This process will probably delay initial steps in the Senate on health care until June, and could result in the Senate refusing to even consider some House-passed provisions (particularly those aimed at modifying Obamacare insurance regulations like those affecting people with preexisting conditions) that run afoul of the ruling.
2. Medicaid will dominate debate in the Senate. The issues that House GOP deliberations focused on from March until yesterday’s passage of AHCA — mostly involving particular groups of people participating in the individual insurance market — may not be as central in the Senate. Vox’s Dylan Scott explains:
The final weeks of the House debate focused on protections for people with preexisting medical conditions who seek to buy private insurance. The amended bill allowed states to curtail some of those protections, with the tradeoff of additional funding that states could use to help insure people who are expensive to cover.
But in the Senate, you can expect Medicaid, the government program that insures upward of 70 million low-income people and was expanded by Obamacare, to take center stage.
During the intra-GOP debate in the House, it was sometimes easy to forget that of the 24 million Americans the Congressional Budget Office estimated would lose health coverage under the original AHCA, 14 million were people enrolled in the 31 states that implemented the Medicaid expansion — which the House bill would briskly shut down.
Ignoring Medicaid won’t be possible in the Senate, where 20 of the 52 Republicans — plus Vice-President Pence — are from states that expanded Medicaid. Governors fearing the massive budget repercussions of an immediate cancellation of the enhanced federal funding that lubricated expansion have run to their senators begging for relief. Some of them are listening. Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, Lisa Murkowski of Alaska, and Rob Portman of Ohio sent a letter to Mitch McConnell back in February warning that they would not accept the kind of abrupt end to the Medicaid expansion that House Republicans were talking about. In a legislative body with a two-vote Republican majority, four senators are a powerful bloc. And, ironically, the possibility of Trumpcare provisions that increase the ranks of the uninsured not covered in the individual or employee-provided insurance markets means even more pressure to cover them under Medicaid.
Adding to the importance of Medicaid, there are conservatives in the Senate as well as the House obsessed with “entitlement reform.” Given the grave political peril of messing with Social Security and Medicare (particularly given the president’s much-repeated opposition to benefit cuts in the big retirement programs), Medicaid may offer the best opportunity for permanent changes in an entitlement program — one that, moreover, affects fewer Republican voters than the others. And so any expansion-state efforts to hold onto a larger Medicaid program benefiting childless, non-disabled adults — the major object of the expansion — will attract some serious conservative pushback. This pushback may take the form of adding work or other requirements to Medicaid eligibility (as the states are allowed to do under the House bill) that are thought to weed out “deadbeats,” or by demands for state-by-state Medicaid spending limits that discourage eligibility enhancements, instead of the “per capita cap” in the House bill that limits spending per beneficiary but not overall costs.
3. There will be another battle over taxes. There is one final factor that observers have barely begun to address: To the extent senators simply add spending to resolve intra-GOP differences on health-care policy, this could mean backing off on some of the Obamacare tax cuts that are in the House bill, since the overall package will need to produce a net positive impact on the budget deficit to comply with reconciliation rules. And though they have received far less attention than they should, it’s the hungry GOP constituencies wanting tax cuts that have kept the drive alive to repeal and replace Obamacare.
If you thought the political calculus that eventually produced House passage of Trumpcare was complicated, you ain’t seen nothing yet.