Sen. Mitch McConnell (R-KY) has taken the expedited, secretive process that the House Republicans used to pass their Affordable Care Act repeal legislation and put it on steroids.
The lack of details about the Senate’s version of the legislation, which stands to affect the insurance coverage of millions of Americans while remaking one-sixth of the economy, is a feature, not a bug, from McConnell’s perspective. Shielding his conference members from scrutiny, McConnell has set up a process that will bypass committee hearings, tamp down outside analysis, and bring a bill to floor for a vote soon after its text is first released publicly.
Senate Republicans said their bill would differ from the House’s repeal measure, but they haven’t elaborated much on how. The potential changes that have been reported don’t appear to alter much its basic outcomes. The House’s American Health Care Act, according to the CBO, would result in 23 million fewer people with health coverage, roll back Obamacare consumer protections, and slash $834 million in Medicaid funding.
GOP senators were told to keep quiet about the negotiations, though they have signaled that once they settle on a set of proposals that would garner support of most of their conference, they’d push it forward quickly.
That moment appears to be arriving, with members gearing up for a vote by as early as before the 4th of July, when Congress is scheduled for recess.
“We need to bring this to an end,” Sen. Lindsey Graham (R-SC) said on Face the Nation Sunday, before bashing the House bill.
“The bottom line is, the Senate is divided between Medicaid expansion states, non-Medicaid expansion states, the proper role of government,” Graham said. “Mitch is trying to bring this together. It’s going to be tough.”
The optimistic timeline is for a draft to be sent over to the Congressional Budget Office in the days to come, with McConnell having already set the procedural stage for the legislation to be brought directly to the floor, sans committee hearings, once the score is in and the conference is ready to vote. It’s unclear when the text will become available for public review between now and the vote, as senior GOP aides indicated to Axios they weren’t going to release the draft they are near completing.
Throughout the negotiation process, McConnell has been resolute without over-promising. Early on, he warned that he didn’t “know how we get to 50,” and some on his leadership team hinted that he’d bring up the bill even if he didn’t have the votes, as a way to move on the tax reform.
Republican senators have vowed that their legislation would look different than the deeply unpopular House version. Judging by what they’ve said about their plan so far, it’s in fact very similar. They’re looking to make the House’s tax credits a little more generous, particularly to older, low income or rural consumers, and fashion a slower phaseout period for the Medicaid expansion. Tweaks to the House’s waivers for states to opt out of ACA insurer mandates have been discussed, but it sounds likely the general idea will remain.
In the last few days, the squabbling over the details of the yet-to-be released bill has grown more public.
“I have some grave concerns about what we’re doing so far,” Sen. Mike Lee (R-UT) said on ABC’s This Week on Sunday.
But the conservative complaints feel like a signal of how close Republicans are to a final deal, rather than a sign that the conference is falling apart.
Senate Republicans are no longer warning of stark, abstract, ideological differences that could doom their legislative push. They’re bargaining over the numbers. Phase out Medicaid in three years or seven? Grow the caps on Medicaid’s federal funding at slower or quicker rate than the House’s inflation metrics?
These are concrete, quantifiable points of difference that can be haggled over, and presumably are being haggled over behind the scenes in the final phase of the discussions. It’s not hard to see the Medicaid expansion standoff resolving itself by splitting the difference, with a five-year phase out. (It’s worth nothing that this “glide path,” as Republicans have called it, still ends in an elimination of the federal expansion programs, and many states may still be inclined to end it quickly, even with the option for a longer taper out period).
The political dynamics in the Senate are echoing the House’s push-and-pull that ultimately got their repeal bill passed. Conservatives are pushing to see how far they can take the bill in their direction, threatening to withdraw their support. The House Freedom Caucus took this negotiating posturing to its extreme by killing the first version of the House bill, before it was updated to weaken protections for pre-existing conditions, despite the vow by many Republicans to protect those consumers. The concession House GOP moderates got in return—an extra $8 billion in funding for risk pool programs—was quite small in comparison.
The pattern seems to repeating itself on the Senate side. Key moderate GOPers from expansion states have come around on eliminating the federal expansion funding, and now the debate is focused on just how long that elimination takes.
Ultimately, McConnell will be seeking to craft a deal that loses only two members of his conference. By shifting the bill towards the center, that may end up being Lee and Sen. Rand Paul (R-KY). (Sen. Ted Cruz (R-TX) has been heavily involved in the negotiations and has avoided throwing any bombs). But that would bank on winning over Sen. Susan Collins (R-ME), who had been extremely critical of the House legislation.
“The Senate bill is still a work in progress. We haven’t seen the actual language. We’re trying to influence the direction of that,” Sen. Susan Collins (R-ME) said on CNN Sunday, while flagging her issues with the House bill’s major cuts to Medicaid.
“Certainly, the outline of the Senate bill is far superior to the House bill, but we have got a ways to go yet,” she said.
Or McConnell can try to secure the support of the conservatives, but at the risk of losing too many moderates. Beyond Collins, both Sens. Lisa Murkowksi (R-AK) and Dean Heller (R-NV) have remained mostly tight lipped about whether they’re comfortable with the direction the negotiations are heading.
A vast majority of the conference appears ready to jump on board with whatever McConnell presents them, even if parts of the bill aren’t exactly what they would prefer.
“I’m comfortable being a part of 51 senators that improves the outcome of America’s health insurance conversation, which requires us to act,” Sen. Tim Scott (R-SC) said last week.
