The Republican health care strategy: Pass bill first, fix it later
Posted July 26
Congressional Republicans have a simple plan to get an Obamacare repeal and replace bill to President Donald Trump: Keep kicking the can down the road.
House Republicans made the argument they needed to pass a bill so the Senate could take it up. Senate Majority Leader Mitch McConnell won a key vote Tuesday by telling colleagues they just needed to bring something -- anything -- to the floor. Now, GOP leaders want senators to do it again: Pass a so-called "skinny bill" so they can work with the House on a final proposal.
Keeping the ball rolling is the name of the game. The actual policy details can wait until what would be an intense conference committee between House and Senate lawmakers.
"What a skinny repeal does is it gets it to a conference committee," said Sen. Mike Rounds of South Dakota. "At that stage, then we can begin the process of rebuilding again as one option."
Already, senators have rejected two significant proposals: One to repeal the Affordable Care Act without an immediate replacement in place, and another to allow bare-bones health insurance plans not permitted under Obamacare.
The "skinny" proposal is a major reduction in the scope of the bill the Republicans first imagined. It would only repeal the individual and employer mandates as well as the medical device tax. Experts have already warned the skinny repeal could drive up the cost of insurance, but it's not the end game. It's a vehicle.
"We've embarked on a conference strategy," said Roger Wicker, a Republican senator from Mississippi.
After the dramatic 51-50 vote Tuesday on the motion to start floor debate on health care, Sen. Bob Corker, R-Tennessee, told reporters that the "real negotiations" would begin once the Senate and House got to a conference.
In private conversations -- as they worked to convince 50 Republicans to vote to begin debating the health care bill -- one leadership aide told CNN "a lot of promises were made about what we'll be able to get for members in a conference."
Health and Human Services Secretary Tom Price, a key negotiator for Trump, said the current need is for the Senate to reach the "lowest common denominator" to keep moving.
"What gets us to 50 votes so that we can move forward on a health-care reform legislation ... that's what needs to happen," Price said on CNBC Wednesday morning.
RELATED: How Mitch McConnell got Republicans past the first hurdle
The Senate strategy is similar to the plan used in the House months ago when Speaker Paul Ryan and his allies were struggling to keep their health care proposal alive. The message then had been that Republican members just needed to send something to the Senate. And then, the negotiations would continue from there.
"None of these votes to me are votes that you ought to live or die by -- they are process votes to move the product along," Oklahoma Republican Rep. Tom Cole, an ally of the leadership, urged House members in March. "You ought to try to continue to amend it, to change it."
The House eventually passed its bill in May with no margin for error, 217-213.
Easier said than done
There are problems, however, with assuming that House and Senate Republicans are going to have any easier time coming up with a comprehensive bill than the Senate did.
It was just a few months ago that Republican senators were boastful that they could find consensus on a plan that would repeal and replace Obamacare on their own. The goal then was to pass something quickly and maybe avoid a messy conference altogether. The House would quickly pass the Senate bill and, send it to Trump and everyone could move on to tax reform having delivered on their long-standing campaign promise.
Only recently has it become clear to leadership that conference is the best strategy now.
During the marathon sessions this week, the thinking is that Republicans will be forced to go on record on various health care proposals. Most of them are expected to fall short of the votes they need, but it will give leadership a clearer indication of which strategy to pursue during conference.
Senate Republican Whip John Cornyn demurred when asked by reporters if leadership had the votes on a "skinny" repeal bill, changing the conversation to the importance of getting to a conference, instead.
"The idea is to try to give people an opportunity to vote on everything they want to vote on and ultimately pass a bill that 50 senators can agree to with the idea of getting to a conference with that," Cornyn said.
Pressed again, Cornyn responded: "If we can pass a bill out of the Senate, we can work with the House."
What would a conference deal look like?
Entering a conference without agreement on their own replacement bill could put senators at a distinct disadvantage as the negotiate with the House, however. Already, the House of Representatives has a health care bill. They worked through their differences and found a way forward after fits and starts. Conference committees are also notoriously arcane and tedious not to mention there are still vast differences between the House's vision for an Obamacare replacement and the Senate's.
House Republicans passed a bill that would end the enhanced funding for Medicaid expansion in 2020 and would give individuals tax credits to buy insurance that were tied to their age, with an income cap.
Senate moderates, meanwhile, have tried to fight to extend Medicaid expansion funding in their states and phase it out beyond the 2020 marker. Senate moderates have also poured billions more into their proposed legislation to ease the transition for low-income people off of Medicaid expansion and to help lower premiums of high-cost patients.
The House bill, meanwhile, gave states the ability to let insurers charge consumers more based on their health history and to waive essential health benefits like maternity care and hospitalization. Versions of the Senate bill have chipped away at those protections, but moderates have made it clear that they are opposed to changes that go as far as the House's did.
In other words, waiting until a conference to find consensus among senators may make the process more grueling and uncertain.
"The differences between House Republicans and Senate Republicans are virtually irreconcilable," Senate Minority Leader Chuck Schumer, D-New York, said on the floor Wednesday morning. "So what is the point of conference?"
For now, however, Republicans are praising McConnell's ability to at least get them to this point.
"He pulled it out of the hat again. He's good at it," said Sen. Jeff Flake of Arizona. "He never quits so we're still working at it obviously, the end game, but at least we started."
Correction: Sen. Mike Rounds represents South Dakota.