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June 27, 2017; Politico

In 1869, American poet John Godfrey Saxe said, “Laws, like sausages, cease to inspire respect in proportion as we know how they are made.” For Senate Republicans and the White House, work on the “Better Care Reconciliation Act of 2017,” better known as the Senate GOP version of “repeal and replace” of Obamacare, is entering further into the sausage-making phase. If you’ve wondered why some of the things that are happening are happening, we’ll attempt to give some insight.

To recap, the Senate received the House-passed American Health Care Act in May. An initially all-male group of GOP Senators was initially announced to work on the bill. Not including a woman in the group was immediately and widely criticized, resulting in a female senator being added the next day and the group opened, at least in theory, to any senator who wished to attend. The bill was drafted behind closed doors, aggravating Democrats and some Republicans. The bill was released by the Senate Budget Committee last Thursday, and the Congressional Budget Office released its “scoring” of the bill on Monday. The bill has received, and will receive, no committee hearings.

The senators were working under a tight deadline advocated by President Trump and Senate Majority Leader Mitch McConnell (R-KY). The desire for speed is based on several reasons. Healthcare legislation has taken up more of Congress’s time than anticipated, crowding out other priorities such as tax reform. Healthcare legislation is technically part of the annual budget reconciliation process, which needs to be completed soon, not only so the federal budget and associated expenditures receive some level of certainty, but also because budget reconciliation will give legislators more information on how to approach tax reform later in the year. Savings gained in the reconciliation process might be available to finance tax cuts, tax credits, and addressing current and potential tax deductions to be included as part of the first comprehensive tax overhaul since 1986. Arguably, the most important reason to complete work on healthcare legislation is that, regardless of party or viewpoint, voters are impatient with their legislators and want them to get things done.

The Senate GOP schedule hit a snag similar to that encountered by House Republicans as they considered the AHCA. In short, several GOP senators, both conservative and moderate, objected to the draft bill in its current form, each seemingly for different reasons. As a result, the bill could not gain sufficient support to be debated on the Senate floor, much less passed. Faced with this reality, McConnell announced that the bill would be delayed until at least July 10, after Congress takes off for the week of July 3–7, 2017, as its July 4th recess.

This break doesn’t mean that senators won’t be working. Senate Democrats will keep up the pressure against the Senate bill in town halls, opinion columns, and media appearances. Meanwhile, GOP senators will use the same tactics to generate support, plus their leadership will negotiate with the holdouts to persuade them to vote for the bill.

The current makeup of the U.S. Senate includes 52 Republicans, 46 Democrats, and two independents (both of whom caucus with the Democrats). A majority is required to pass budget reconciliation bills, unlike most Senate legislation which requires 60 votes to avoid the dreaded filibuster. Since the Vice President can cast a vote to break ties, and Vice President Pence is a Republican, 50 senators must vote in favor of the bill and rely on Pence to cast the tie-breaking vote. Since all Senate Democrats are ready to vote against the bill, the GOP can only lose two votes from its caucus and still pass the bill.

When it scored the bill, the CBO estimates gave the Senate GOP leadership $188 billion in unanticipated savings which can be used to sweeten the pot for the reluctant. Sens. Ted Cruz (R-TX) and Mike Lee (R-UT), for example, would like the bill to place more emphasis on allowing individuals to build tax-free health savings accounts (HSAs). Sen. John Thune (R-SD) said, “It wouldn’t be a bad thing if we put the money toward deficit reduction.” Senate moderates would like to see more spending to address the opioid epidemic and would prefer to see more money spent on Medicaid. Sen. Susan Collins (R-ME) is concerned about Medicaid cuts as well as the one-year prohibition on Medicaid reimbursements to Planned Parenthood included in both the House and Senate bills.

As NPQ has reported, this is only one phase of a laborious process that will continue even if the bill passes the Senate. And, as House Speaker Paul Ryan explained earlier this year, the GOP budget reconciliation bill is only one step in a three-pronged effort to repeal and replace the Affordable Care Act. The other two prongs involve federal regulatory changes not requiring Congressional approval (the ACA gives the Secretary of Health and Human Services (HHS) wide discretion in how the ACA is administered) and federal legislation required to address narrower, specific aspects of healthcare.

The process can be ugly and disquieting to watch, especially for those most directly affected by potential changes, including nonprofit healthcare providers and their patients and clients. When the sausage-making is at its most intense is precisely when it’s most important to pay attention. The details matter, and advocates need to know how the details came to be included (or excluded) from the legislation and why the bills succeed or fail. And, for another example of what’s at stake when the Congressional sausage gets made, read “ADAPT Activists to Media and Progressives: Check Yourselves.”—Michael Wyland