GOP senators gloomy about repeal prospects, but watch out for House repeat

The seeming impasse among Senate Republicans to reach an agreement on how to repeal and replace the Affordable Care Act feels like déjà vu all over again.

The question is which senator will take on Republican congressman Fred Upton's role and broker a last-minute compromise. Upton's amendment in early May brought just enough moderates and conservatives together to pass the American Health Care Act in the House.

Late last week, after the nonpartisan Congressional Budget Office walloped the House GOP replacement bill by estimating it would spike the number of uninsured Americans by 23 million, Senate Republicans wrung their hands, acknowledging it would make their repeal-and-replace efforts more difficult. Some dreaded the hostile reception they might get back home during the Memorial Day recess.

"If I had to bet my house, I'd bet we don't get it done," an unnamed GOP senator told Politico.

Even normally unflappable Majority Leader Mitch McConnell said he didn't know how his party would get the needed 50 of the 52 Senate Republicans to pass a healthcare bill under special budget reconciliation rules requiring only a simple majority (Vice President Mike Pence would provide the 51st vote to pass the bill).

McConnell's drafting group of 13 senators began writing the Senate's bill at the end of the week, even though the GOP caucus remains far from agreement on many key issues, including phasing out the ACA's Medicaid expansion, structuring premium tax subsidies, capping Medicaid spending, letting states opt out of the ACA's insurance market rules, and whether to repeal all of the ACA's taxes that finance expanded coverage.

There is also discord over whether to end funding for Planned Parenthood, which at least three Republican senators oppose.

Prominent political reporters at the New York Times, the Wall Street Journal, and Politico wrote quasi-obituaries for the Senate's struggling healthcare effort, with headlines like "GOP turns gloomy over Obamacare repeal."

But don't forget that nearly everyone had written off the chances of House Republicans passing their repeal-and-replace bill after Speaker Paul Ryan and President Donald Trump withdrew their bill without a vote in late March. Ryan declared that "Obamacare is the law of the land" for the foreseeable future. Even three days before the AHCA passed on May 4, it was dubbed "zombie Trumpcare" —a dead bill that didn't know it was dead.

Opponents of the GOP repeal-and-replace effort, including many healthcare industry groups, were lulled into complacency thinking the bill was going nowhere.

Then Rep. Upton—who a day earlier said he couldn't vote for the AHCA because it weakened protections for people with pre-existing medical conditions—proposed an amendment offering $8 billion for high-risk pools to cover otherwise uninsurable people. Critics called that a fig leaf giving more centrist GOP lawmakers cover to reverse themselves and vote for the bill; but it worked, enabling Ryan to squeak the bill through on a 217-214 vote.

The same could well happen again, ACA supporters and opponents say.

"McConnell is probably the most effective leader on the GOP side in corralling votes, and anyone underestimating his ability to bring his caucus together does so at their peril," warned Ron Pollack, chair emeritus of Families USA, who helped build support for passage of Obamacare.

"I'm betting today that you get two-thirds of the House bill through the Senate," said Tom Scully, who headed the CMS under President George W. Bush. "The odds are better than 50-50."

While there's lots of talk about relative moderates from Medicaid-expansion states, such as Ohio Sen. Rob Portman, serving as a firewall against the House bill's repeal of the Medicaid expansion, those senators have indicated they are amenable to compromises. Portman said he wants a "soft landing" for states that expanded coverage to low-income adults. He's reportedly seeking a delay of several years in the phase-out of enhanced federal funding for the expansion population.

"A delayed cut is still a cut with long-term repercussions," Pollack said. "I worry whether the moderates will provide the kind of resistance to things that will harm their constituents that they appeared to be signaling early on."

That's why pro-ACA observers fear another Upton-type surprise in the Senate, with some GOP senator proposing modest changes to give cover to moderates to vote yes on the bill, despite big coverage losses and erosions in consumer protections that they previously opposed.

"Senate moderates are going to be under the same enormous pressure moderates faced in the House," said former Democratic Senate Majority Leader Tom Daschle. "Only time will tell if they cave in a similar fashion."

Many healthcare industry leaders, particularly in insurance, are keeping a low profile while they wait to see the shape of the legislation Senate Republicans produce.

But that strategy could be risky, because the Senate bill could make a rapid recovery from intensive care. Senate GOP leaders are determined to make that happen because they must pass their healthcare overhaul first to enact permanent large tax cuts later this year.

"Doing nothing is not an option," Senate Majority Whip John Cornyn of Texas said Thursday.

Billy Wynne, a former Democratic Senate staffer and healthcare lobbyist who represents hospitals and other industry groups, advised healthcare groups to press their positions on senators as strongly as possible now.

"Don't take anything for granted," Wynne said. "You can think something is dead, but then all of a sudden it's not."