The Senate's 4 Big Problems With Health Care

Jun 5, 2017
Originally published on June 5, 2017 9:44 pm

Republicans are running way behind schedule.

In the dream scenario outlined by party leaders back in January, President Trump would have signed legislation to repeal and replace the Affordable Care Act, also known as Obamacare, months ago. By early June, Republicans were supposed to be in the thick of overhauling the tax code.

Here's the reality: The GOP health care debate is stalled in Congress, and its uncertainty has clogged up the legislative pipeline to Trump's desk. Republicans can't move on — and many are ready to do so — until they resolve the fate of their long-promised health care bill.

Here are four big problems standing in the way.

1. Lack of momentum

"I don't see a comprehensive health care plan this year," Sen. Richard Burr, R-N.C., told a local TV station on Thursday.

Nearly a month after the House passed its version of the health care bill, 13 GOP senators have had weeks of closed-door meetings but so far have failed to produce any discernible progress on health care. The one piece of consensus is that the House-passed American Health Care Act is a non-starter in the Senate.

Senate Majority Leader Mitch McConnell, R-Ky., was candid about the bill's status in an interview with Reuters before the Memorial Day break. "I don't know how we get to 50 [votes] at the moment. But that is the goal. And exactly what the composition of that [bill] is I'm not going to speculate about because it serves no purpose," McConnell said.

McConnell has little room for error. With a 52-seat majority, he can only lose two votes and pass a health care bill, with Vice President Pence as a tiebreaker. But warring factions of Senate Republicans remain sharply divided on their priorities.

2. Policy disagreements

Conservatives like Sens. Ted Cruz of Texas and Mike Lee of Utah say they can't support any legislation that won't demonstrably lower premium costs. To that end, they have floated a proposal to repeal the ACA's insurance regulations or to let states opt in to the ACA's standards. Those regulations include protections for people with pre-existing conditions and mandates on what services insurance plans have to cover on the individual market — the "essential health benefits" that became a big part of the debate in the House this spring. In sum, the proposal would allow for plans that are less expensive, mainly by allowing people to attain less coverage.

But doing so would likely lose the votes of more centrist Republican senators, like Susan Collins of Maine and Bill Cassidy of Louisiana. That duo has been working on their own legislation that would allow states to keep Obamacare intact and more broadly keep popular parts of the bill in place. But their proposal alienates conservatives who have derided it as "Obamacare-lite."

There are also divisions among Senate Republicans from states that took the Medicaid expansion with federal funding and those from states that rejected that money. One key issue is how, and how long, to let states keep the expansion in place or to create a timeline to wind it down.

3. Rules not meant to be broken

All of this is happening in a chamber with much more restrictive rules on what can be included in the bill than in the House. Republicans are producing a health care bill under "reconciliation" — the budget process to allow legislation to pass with 51 votes in the Senate instead of 60, eliminating the need to get any Democrats on board. One issue is that the House bill included language that prevents individuals from using tax credits to purchase insurance plans that cover abortion services. This provision is unlikely to pass the Senate's "Byrd Rule," which aims to block senators from using this fiscal process to include policies unrelated to taming the deficit.

While a vote is not in sight, multiple aides close to the negotiations say that senators are acting in good faith and that everyone wants to get to "yes" on a bill — they just have no idea what that bill looks like. How to craft a bill that can win over warring factions and pass procedural hurdles is a question without an answer.

4. A ticking clock

The pressure to act — or move on — is building. The reconciliation protections to pass health care with 51 Senate votes expire at the end of September — but senators and aides are operating under an assumption that if there is no bill by the August break, then hopes for health care legislation have likely tanked.

June could be a make-or-break month for the bill because, if the Senate has to negotiate a final bill with the House, it will likely need to be close to a deal by the July Fourth recess — just four weeks from now.

Health care is also holding up the rest of the agenda. Congress can't move on to next year's budget resolution — which sets up the framework for tax reform — until health care is complete, because of congressional rules.

On top of that, Treasury Secretary Steven Mnuchin has already asked Congress to vote to lift the debt ceiling before lawmakers go home for the month of August, setting up a partisan fight over spending.

Congress also needs to start work on spending bills to fund the government for the next fiscal year. If legislators go home for the August recess, they will only have four weeks in September until the 2018 fiscal year begins, at which point the government runs out of funding unless Congress does something to supply more money on a short- or long-term basis.

The motivation to act on health care is driven in part by the political discomfort over the party's failure to hand Trump any major legislative victories as Congress approaches the 2017 halfway mark. But if there is no fresh progress as talks roll on into June, the motivation may shift toward winnable legislative battles.

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The Senate is back in session today for the month of June, and it's an important month. It could make or break the Republicans' health care bill. Senators spent the last month deciding what they don't like about the bill that was passed by the House, but they can't seem to agree on what to do about it.

NPR congressional correspondent Susan Davis is with us to talk about one of the most contentious debates happening on Capitol Hill. Hey there, Sue.


MCEVERS: So how's the debate going as of today?

DAVIS: Not great. You know, Congress is coming back today from a week-long recess. Senators were back home, hearing from their constituents. And tomorrow they're going to meet in their regular Tuesday meeting, and Senate Republican leaders and the party chairmen are going to lay out their options.

I haven't found any optimists here. There's been a 13-member working group made up of Republicans who spent the first month - you know, recall the House passed their legislation in early May, and then the Senate took the month of May and really dissected all the parts of the House bill that they don't like. But they haven't really figured out how to take apart that bill and put it back together again in a way that can pass the Senate.

As the majority leader, Mitch McConnell, said right before the break in an interview with Reuters, he said, right now there is no bill that can get 50 votes in the Senate. And we'll maybe have a better sense tomorrow if there's been any progress on that front.

MCEVERS: Well, what are the main issues that the Senate is trying to resolve?

DAVIS: I would say there's three main issues. The first would be the tax credits, which is, the Senate can't decide how much to give people to buy insurance on the individual market. The House bill just gave tax credits based on your age. There's a lot of debate in the Senate to also peg that to your age and your income. So that makes sure that older people don't have to pay more.

By far the biggest issue, though, is Medicaid and what to do with the program both in terms of the Medicaid expansion under the Affordable Care Act that allows people to - provides more health coverage to people and as well as what they want to do to remake Medicaid to shift it into a program for states that's either a block grant or a per capita system. So states would get finite amount of money instead of the open-ended guarantee they have now.

So you have debates among senators from states who took the expansion versus the senators who didn't take the expansion and broader concern that how you - they want to make sure that how they remake Medicaid doesn't hurt the neediest of Americans - remember; the people that Medicaid helps the most - children, elderly and the disabled. I would also say that rolling back the Affordable Care Act's regulations that mandate certain elements of insurance coverage and the preexisting condition protections are also another issue.

And so striking this balance is really hard. For every couple of conservatives you bring onboard, you lose a couple of moderates and vice versa. And McConnell doesn't have a lot of room for error. He can only lose two votes and still get a bill through the Senate.

MCEVERS: This health care bill has dominated the legislative agenda all year. Why is this month so important?

DAVIS: You know, there's a political sensitivity to the fact that Republicans are approaching the halfway mark of this year. And they control all the levers of Congress and the White House, but they haven't really sent President Trump any major legislative victories. So there's an element of just wanting to move on.

In the beginning of the year, the speaker, Paul Ryan, and the majority leader, Mitch McConnell, wanted to have health care wrapped up by early April. Obviously that has not happened. There is a very strong desire to move on to other issues, including overhauling the tax code, and there's just an actual demand that there's other issues they need to address. They need to decide on spending bills for next year. And Treasury Secretary Steve Mnuchin has already asked Congress that he would like them to vote to raise the debt ceiling in July before the August recess. So they need to move on.

MCEVERS: If the Senate can't pass a health care bill, what would that mean for health care legislation?

DAVIS: Well, if they can't pass anything under reconciliation, which is the process they're using that allows it - that protects it from a filibuster, which means they don't need Democrats - if they can't use that system, it means they're going to need Democrats. Failing would in some ways acknowledge that this is just a problem that can't be solved with Republicans alone.

And there are several senators, like Bill Cassidy of Louisiana, Susan Collins of Maine, who have been arguing this all along, who've been saying, we should really pull in Democrats. We need 60 votes. We need bipartisan buy-in to do that. If they can't vote on anything, it would mean that the mission is shifting away from repeal and replace to repair. And it would maybe be a tacit acknowledgement from Republicans that the Affordable Care Act is the law of the land.

MCEVERS: And that would be interesting to see what would happen with that then in the House.

DAVIS: Absolutely.

MCEVERS: NPR's Sue Davis, thanks so much.

DAVIS: You bet. Transcript provided by NPR, Copyright NPR.