Sen. Susan Collins (R-Maine) is one of the swing votes on health care. But she is not in Mitch McConnell's working group. (AP Photo/Andrew Harnik, File)

THE PROGNOSIS

If repealing Obamacare was a marathon, Republicans have only made it past the first few mile markers. They face a long, steep road ahead in the Senate, filled with procedural and political potholes that could derail them at every turn.

It was exhausting to follow the daily twists and turns as the House GOP struggled over the past two months to pass their measure overhauling big parts of the Affordable Care Act. So it’s hard to believe that was the easy part -- yet it was. The heavy lift’s in the Senate, where Republicans face an even narrower path to success (they can only lose two of their own in a chamber with 52 Republicans and 48 Democrats) and where they must squeeze health policy into the narrow confines of a budget bill.

Think of the eventual Senate bill as a close sibling of the House bill -- but certainly not its twin. Thirteen Republicans, selected by Majority Leader Mitch McConnell (R-Ky.), are working on legislation that may look quite different from the House measure once all’s said and done. And that’s assuming they’re even able to come up with a bill that could both get approved by the Senate parliamentarian and attract the 50 votes needed to pass it.

The group is meeting today to discuss Medicaid changes. Still, most Senate-watchers agree none of this will happen very quickly, so we’re gearing up for a long, but not lazy, summer. McConnell has been silent on a timeline, but fired off some angry Obamacare tweets yesterday.
 

Pages could be written on all the challenges stacked up against Senate Republicans trying to ditch the current law.

But for you, readers, here are five dynamics to watch that will determine if the Senate can get to the 51 votes needed to pass its form of health care:

Rev. Jim Wallis meets with Sen. Kelly Ayotte (R-N.H.), Sen. Lisa Murkowski (R-Alaska) and Sen. Susan Collins (R-Maine) in front of the Capitol Building on Oct, 16, 2013 in Washington, D.C. (Photo by Andrew Burton/Getty Images)

1. Moderate senators will insist on reversing some of the Medicaid spending cuts.

Republican senators from Alaska, West Virginia, Maine and Ohio have already objected to how the Republican health-care bill would cap Medicaid spending, writing in a March letter to McConnell that it doesn’t include “stability” for people who were newly eligible for the program in the last few years. 

The letter was signed by Sens. Lisa Murkowski, Shelley Moore Capito, Susan Collins and Rob Portman, who are all under heavy pressure to ensure coverage gains under the Affordable Care Act aren’t rolled back. 

--But restoring some of the Medicaid spending could jeopardize an aspect of the bill that is a winner for Republicans -- its estimated $150 billion in savings over a decade. And it could alienate conservatives, who are under pressure from groups like Heritage and Americans for Prosperity to slash federal programs.

 

Sen. Jeff Flake (R-Ariz.) before an Arizona Chamber of Commerce event on April 7, 2015. (For the Washington Post/ Laura Segall)

2. About 20 Republican senators live in states with Medicaid expansion, including two in tight races next year.

Besides capping overall Medicaid spending, the GOP plan would also slash extra federal funding for states that expanded their programs under the Affordable Care Act. That has a number of Republicans wary, most notably Sens. Jeff Flake of Arizona and Dean Heller of Nevada, both facing tough reelections next year.

Of course, the fact that Flake and Heller are the only two truly vulnerable Republicans up in 2018 could also bode well for efforts to roll back Medicaid, as Republicans weigh the immediacy of their political risks.

 

Sen. Rand Paul (R-Ky.), a member of the Senate Foreign Relations Committee on Capitol Hill on April 7, 2017. (AP Photo/J. Scott Applewhite)

3. The most likely GOP defectors from the House bill are: Sens. Collins and Murkowski (moderates) and Sen. Rand Paul (libertarian/conservative). Republicans can lose only one of these three lawmakers and still pass health care.

Besides protesting the bill’s Medicaid cuts, Collins and Murkowski have also said they dislike how it would slash funds to Planned Parenthood for one year. Notably, neither of them are in the 13-member working group.

If McConnell loses both their votes, he’d have to win over every single other Republican -- including Paul, the most likely conservative to defect from the House bill. Removing Planned Parenthood defunding from the bill is one way McConnell could win over Collins and Murkowski, were he to lose Paul.

 

Sens. Ted Cruz (R-Texas) and Mike Lee (R-Utah) speak during a Senate Judiciary Committee meeting on April 3, 2017. (Photo by Matt McClain/The Washington Post)

4. Conservatives will try to pull the bill toward a fuller Obamacare repeal.

Speaking of Rand Paul, he was the most vocal senator to ally with the House Freedom Caucus while its members were demanding that the GOP health plan repeal more of the law’s insurance regulation -- indicating he's ready to cause a ruckus in the Senate, too.

Paul, along with Sens. Ted Cruz (Texas) and Mike Lee (Utah), could dramatically complicate things for Senate leadership by insisting on further steps in that direction. To move the bill in a more conservative direction, they could also try to switch its refundable tax credits to nonrefundable tax credits or cut off the federal funding for Medicaid expansion enrollees sooner. Both Cruz and Lee will have input in the Senate bill, as they're among the Gang of 13.

5. And then there’s the Senate parliamentarian.

Trying to repeal even more of Obamacare’s insurance regulations could backfire. As it is, the House health bill already contains some elements that very well may be stripped out by the Senate parliamentarian because they don’t affect spending directly, as is required under the special budget rules that allow Republicans to seek the magic 51 and not 60-vote number.

In other words, the Senate may not even be able to tackle the House bill if the parliamentarian decides much of it doesn't meet what's known as "Byrd rule" standards. This is the first hurdle the bill must tackle and it could result in major parts getting stripped out, or even death to the entire bill.

 

AHH, OOF and OUCH

AHH: There's been much talk of how the GOP health care bill would affect coverage on the individual market, but NYT's Margot Sanger Katz explains how it could affect employer-sponsored coverage as well. Employers would find it easier to increase premium contributions from employees or stop offering coverage altogether. It also has potential for weakening the ACA's rules against capping worker benefits or limiting their contributions to deductibles or copays.

OOF: Sen. Bill Cassidy says there should be a "Jimmy Kimmel" test for any health-care measure, to make sure patients with preexisting conditions (like Kimmel's own son) can get coverage. The Louisiana Republican, who has introduced his own bill -- which some conservatives termed "Obamacare forever" -- appeared on Kimmel's show last night to discuss health care. Interestingly, Cassidy said the Senate needs to ensure premiums are lowered because the House bill would raise them.

OUCH: Fewer than one-third of Americans like the Republican health care bill, according to a new HuffPost/YouGov survey. That's even fewer than have generally supported the Affordable Care Act for the past seven years. Still, this thought might hearten congressional Republicans (or just depress them): Their Obamacare replacement is more popular than they are.

HEALTH ON THE HILL
House Speaker Paul Ryan, left, talks with the media with Rep. Rod Blum on Nov. 2, 2016, in Waterloo, Iowa. (Matthew Putney/The Courier via AP)

--It's been five days since House Republicans passed their bill replacing some of the biggest parts of Obamacare. The measure would dramatically scale back government benefits, a pretty much unprecedented action. "The government can giveth, but it can almost never taketh away," Jeremy Peters writes in the New York Times.

"As they take their victory lap for passing a bill that would repeal and replace much of the Affordable Care Act, President Trump and congressional Republicans have been largely silent about one of the most remarkable aspects of what their legislation would do: take a step toward dismantling a vast government entitlement program, something that has never been accomplished in the modern era," Peters writes.

--Freedom Caucus Chairman Mark Meadows told the Huffington Post that he's already been working with conservatives on what changes to the measure he helped craft conservatives in the Senate could accept -- and he acknowledged the bill will likely move towards the center.

“If it’s moving to the left, we just need to make sure we’re not losing too many conservative votes,” Meadows said. “Obviously it’s going to get more relaxed as it relates to the Medicaid expansion.”

--Just a handful of Republicans who voted for the American Health Care Act braved town hall meetings yesterday as House lawmakers went home to their districts right after the big vote. Among them: Freedom Caucus member Rod Blum of Iowa, who had a rough, rough day and night. First, Blum walked out of a TV interview when asked to explain why his staff was prescreening constituents who planned to attend. A few hours later, the prescreened audience mostly screamed at him.

My colleague Ed O'Keefe was there to witness it all. He writes, "The way Blum struggled Monday night to explain his vote — through the loud boos of rowdy, impolite and infuriated constituents — is just a narrow sampling of the the growing concern and confusion caused by Republican plans to revamp the nation’s health-care system. But it indicates the difficult balancing act many Republican lawmakers from swing districts will need to strike as the complex debate continues in Washington."

At one point, a woman advanced toward Blum while yelling at him to explain why he voted for a bill cutting billions from Medicaid. Ed got a video of that: 

--House Republicans got heat from their Democratic colleagues, too. One House Democrat, Rep. Sean Patrick Maloney (N.Y.), traveled yesterday to a neighboring district represented by Rep. John Faso (R-N.Y.), saying he'd explain Faso's vote for the health-care bill to his constituents if Faso wouldn't do it himself.

"If it takes an adopt-a-district program where you have to get a responsible congressman to stand in and answer the question, then that's exactly what we're going to do," Maloney told attendees.

--Rep. Labrador (R-Idaho) is still feeling the outrage over his weekend comment at a town hall that "individuals won't die without health care." Sen. Kamala D. Harris (D-Calif.) had a choice response. "What the f--k is that?" she said on a podcast interview. 

--Two former Obama administration officials are creating their own town hall action this week. Andy Slavitt, who played a key role in the Obamacare marketplaces, is holding two telephone meetings today to stir opposition in West Virginia and Nevada against the GOP plan. We're told Slavitt will also travel to Sierra Vista, Ariz., on Friday, to meet with constituents of Rep. Martha McSally (R-Ariz.), who voted for the bill. Former HHS Sec. Kathleen Sebelius spoke yesterday with constituents represented by McSally and Rep. Bruce Poliquin (R-Maine).

INDUSTRY RX
Drug pricing was the elephant in the room, but it apparently stayed in the corner according to National Institutes of Health Director Francis Collins.
Across 32 states, more than 400 free-standing ERs provide quick and easy access to care. But they also are prompting complaints from a growing number of people who feel burned by ­hospital-size bills, like $6,856 for a cut that didn’t require a stitch or $4,025 for an antibiotic for a sinus infection.
MALPRACTICE

Here at The Health 202, we get sort of stressed out when politicians misspeak -- or intentionally mislead -- about health policy. And it’s relatively easy to do, because who really knows up from down in this messy world? Here, we highlight the most egregious offenders and try to set the record straight. Consider this space our contribution to facts -- because they matter.

--First on our radar: Health and Human Services Secretary Tom Price, who told CNN over the weekend that the GOP health-care bill won’t cut Medicaid spending:

“Remember that there are no cuts to the Medicaid program,” Price said. “There are increases in spending, but what we’re doing is apportioning it in a way that allows states greater flexibility to cover their Medicaid and care for their Medicaid population.”

--The facts: According to the Congressional Budget Office, the American Health Care Act would cut Medicaid spending by $839 billion over a decade, resulting in 14 million fewer enrollees by 2025. Not only would the bill cut extra federal spending for Obamacare’s Medicaid expansion; it would also cut the program overall by basing payments on enrollees instead of a percentage of overall costs.

It’s becoming rather fashionable for Republicans to dismiss estimates from the nonpartisan CBO, ever since the agency rendered a less-than-favorable verdict on the original GOP health bill (the final measure with several amendments wasn't even scored to determine its cost and how many people might lose their insurance).

--To be fair: When Price referred to “increases in spending” he may have meant that the federal program will still spend more on Medicaid every year, albeit at a lower spending level overall than what would have occurred under Obamacare. Like over the weekend when my husband trimmed the shrub covering our front window; it will keep growing all summer, but starting from a smaller size.

“Remember what the $880 billion is off of, it’s off what’s called a baseline, which is what the federal government—what the Congressional Budget Office—says we would spend if we just continued under current law,” Price said.

To put all this in perspective: The federal government is projected to spend about $459 billion on Medicaid in 2020. The GOP bill would reduce spending by $64 billion that year, around a 14 percent cut. There are important arguments to be had about how much the federal government should pay for health insurance for low-income people. But the bottom line here is: The Republican bill cuts Medicaid, and by quite a bit.
 

STATE SCAN
Liberal-run states might move to roll back the law's coverage requirements, if subsidies are limited under the GOP health care law and policymakers are forced to find other ways to cut costs.
More than half the low-income people who qualified for Indiana’s alternative Medicaid program failed to make a required monthly payment for the top tier of benefits.
Former Rep. Tom Perriello — running against a doctor in the Democratic primary for Virginia governor — is banking on health care to turn out his voters
The District of Columbia and Loudoun County have gains in longevity; eight Kentucky counties have the worst decreases.
SUGAR RUSH

Watch Rod Blum walk out of a TV interview:

Watch Sen. Kirsten Gillibrand (D-N.Y.) talk the GOP health bill on “Ellen:"

Here are five things to know about fetanyl: