After being resuscitated by sheer willpower, the American Health Care Act of 2017 is breathing again. Thanks to what was undoubtedly a tremendous effort by President Trump, Speaker Ryan, and several others, the plan to repeal and replace Obamacare has passed the House and now heads to the Senate. Its future is uncertain – indeed, the only thing you can be sure of is that whatever comes out of the Senate will look different than what the House sent over.
The first major obstacles that the AHCA will face are simply the culture and rules of the Senate. The lower chamber tends to be more methodical when it comes to legislation. “’We’re not under any deadline, so we’re going to take our time,’ Sen. John Cornyn (R-TX), the majority whip, told reporters,” according to NBC. The Senate also has a rule that any new law which impacts the budget must be scored by the Congressional Budget Office first before it can go up for a vote. This requirement alone will add at least one to two weeks.
Furthermore, the rules of the Senate allow for a filibuster on most bills. Because the odds of any Democrats voting to repeal and replace Obamacare are slim to none – with the possible exception of Sen. Joe Manchin (D-WV) – the GOP needed to turn to a legislative process called reconciliation to get around the threat of a filibuster. Reconciliation allows a bill to pass with a simple majority (with the Vice President breaking any tie). The downside is that the bill may only contain provisions which affect the federal budget. Anything that does not will be stripped out. Who decides what stays and what goes? That would be the unelected Senate Parliamentarian, a woman named Elizabeth MacDonough who was appointed by Harry Reid (D-NV). In 2015, she was responsible for preventing the reconciliation process to be used on an earlier bill designed to repeal parts of Obamacare. She may once again be a key player.
The second obstacle that the ACHA will face in the Senate is the cast of characters within the GOP itself. While the House vote could afford to (and did) lose a relatively large handful of GOP votes, the margin for loss in the Senate is much smaller. Will the ideological Paul, Cruz, or Lee argue that the plan does not go far enough to repeal Obamacare and vote no? Will the centrist Collins and Murkowski vote no based on the fact that bill defunds Planned Parenthood over the following year? With the several Senators who previously voiced objections to shrinking federal funding for Medicaid withhold their support? Any combination of more than two of these names will doom the bill. Any modifications to the proposal to make it more moderate would require another vote in the House which may fail if the changes alienate too many Freedom Caucus members.
Lastly, many in the Senate appear to be opposed to even considering the House draft. Shortly after the Speaker Ryan concluded his vote, several members of the Senate hinted at the idea that they would simply create their own bill from scratch. Such an effort is likely to look significantly different than the House bill, leading to an even longer process where both groups attempt to arrive at a consensus. To drive home just how wide the gulf is, consider the following. Instead of creating waivers for states to opt out of certain Obamacare requirements, as the House bill proposes, one of the leading concepts in the Senate is essentially the opposite approach. The Senate alternative is to give states the option to opt into an entirely new program where people would be automatically enrolled in catastrophic coverage. Indeed, the gulf between these two plans is vast.
Regardless of what happens, the excitement appears to be over for now. Over the next several weeks, America will wait while the Senate gets their chance at reforming health care. Once they settle on their bill, we will see if the American Health Care Act flatlines once again or is finally able to walk to the White House. Either way, it will have surely been through some serious plastic surgery.