House Republicans journeyed to the White House on Thursday for a health-care victory lap in the Rose Garden, but Senate Republicans were in no mood for celebration.
“It’s going to be a Senate bill, so we’ll look at it,” Sen. Jeff Flake (R-Ariz.) said.
“We will be working to put together a package that reflects our member’s priorities with the explicit goal of getting 51 votes,” Sen. Orrin G. Hatch (R-Utah) said.
Now that the House has narrowly passed legislation overhauling the nation’s health-care system, the measure is headed to the Senate, where Republican leaders will wrestle with political and procedural challenges complicating chances for final passage.
Republican senators are signaling that their strategy will be rooted in crafting their own replacement for the Affordable Care Act. It remains unclear how closely that measure will resemble the one that narrowly passed in the House on Thursday or whether GOP senators will resolve their stark differences.
A small group of Republican senators met Thursday morning in the office of Senate Majority Leader Mitch McConnell (R-Ky.) to begin outlining their health-care priorities, said Sen. John Cornyn (R-Tex.), McConnell’s top deputy.
"It was designed by the leader to be a smaller group of people that represent the different perspectives and points of view in our conference," "If that group can get to 'Yes,' then [we will] take it to the rest of the conference," Cornyn said.
Cornyn would not commit to a timeline for a Senate vote, simply saying, “When we get 51 senators, we’ll vote.”
Republicans hold a 52-to-48 advantage over Democrats in the upper chamber, leaving GOP leaders with a narrower margin for error than in the House, where infighting among Republican lawmakers nearly derailed the push on multiple occasions.
Signaling the frustration some Republican senators already have with the House bill, Sen. Lindsey O. Graham (S.C.) posted a skeptical note Thursday on Twitter: “A bill — finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate — should be viewed with caution.”
Senate Republicans have opted to use a maneuver known as reconciliation to try to pass the bill with a simple majority instead of having to clear the 60-vote threshold required for most legislation. In the current balance of power, that would require Democratic votes. Even getting to a simple majority will be no small task.
GOP senators from states that have expanded Medicaid under the Affordable Care Act, such as Sen. Rob Portman (Ohio) and Shelley Moore Capito (W.Va.), have voiced concerns about rollbacks to that program in the House bill.
"Absolutely," replied Capito, when asked if she has still has worries.
Meanwhile, three conservative GOP senators — Ted Cruz (Tex.), Mike Lee (Utah) and Rand Paul (Ky.) — are also wild cards.
They have been willing to buck party leadership: Earlier this year, they pushed for a more aggressive repeal of the health-care law than many of their colleagues favored.
“I think that the House Freedom Caucus was able to make the bill a lot less bad,” Paul said. “I think there’s still some fundamental problems that I have with it.”
Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) have already introduced an alternative plan, giving lawmakers a second measure to look at should talks over the current bill fall apart.
Then there are the procedural hoops that Senate Republicans must clear, which could steer them to strip away some of the House bill’s signature provisions.
The measure’s original version, introduced in March by House Speaker Paul D. Ryan (R-Wis.), already contained elements at risk of being struck out in the Senate under budget reconciliation rules that allow tax and spending changes but not broader policy changes.
That proposal initially left many of the ACA’s insurance regulations alone — with the goal of ensuring it would pass muster with the Senate parliamentarian, a nonpartisan officer of the Senate who decides on what may go in a reconciliation bill — but not all of them.
The version of the bill the House passed Thursday undercuts the ACA’s insurance regulations even more by giving states a path to opt out of federal requirements for insurers to cover certain “essential” health benefits — and to allow them to charge sick people the same premiums as healthy people.
The GOP bill would allow insurers to charge older Americans five times what they charge younger people, as opposed to three times as much under current law.
And it would enable insurers to increase premiums by 30 percent for people who do not remain continuously covered. Health policy experts, including conservative ones, have noted that the parliamentarian may decide those provisions need to be stripped out.
Additionally, members of the House voted on their bill before they received a score from the nonpartisan Congressional Budget Office, which measures how much the legislation would cost and how many people stand to lose coverage under it. Senate budget rules require a CBO score that proves the legislation will not increase the deficit after 10 years. the Senate parliamentarian can't even start reviewing the AHCA without a score from the CBO,which is expected to take several weeks.
"I sincerely hope the Senate won't mimic the House and try to rush it through without hearings or debate or analysis," said Senate Minority Leader Charles E. Schumer (D-N.Y.).
The CBO projected in late March that an earlier version of the GOP health-care plan would result in 14 million more people being uninsured in 2018 than under current law. It projected the plan would slash the federal deficit by $150 billion between 2017 and 2026.
Even if Senate Republicans pass their own version of a health-care overhaul, it would have to be reconciled with the House version, creating complications. And if getting House conservatives and moderates to pass their initial measure was a challenge, it could be next to impossible to get enough of them to sign on to whatever the Senate decided to pass.
Rep. Mark Meadows (R-N.C.), chairman of the hard-right House Freedom Caucus that Paul referenced, said he will not necessarily back any changes made by the Senate.
"Obviously, the upper chamber has their own personalities and their own agendas," Meadows said. "Certainly, it's their agenda and not mine."
“If they revise it, there’s no way,” Rep. Dave Brat (R-Va.), another Freedom Caucus member, said this week. Brat refused to support the Ryan bill until provisions were added for states to opt out of more insurance regulations.
“Have you been watching for the last few months how tight this is, and you’re going to shift this one or the other?” Brat said. “Good luck. You don’t have to be Einstein to game theory that one.”