After weeks of will-they-or-won't-they tensions, the House managed to pass its GOP replacement for the Affordable Care Act on Thursday by a razor-thin margin. The vote was 217-213.
Democrats who lost the battle are still convinced they may win the political war. As the Republicans reached a majority for the bill, Democrats on the House floor began chanting, "Na, na, na, na ... hey, hey, hey ... goodbye." They say Republicans could lose their seats for supporting a bill that could cause so much disruption in voters' health care.
Now the bill — and the multitude of questions surrounding it — moves across the Capitol to the Senate. And the job doesn't get any easier. With only a two-vote Republican majority and likely no Democratic support, it would take only three GOP "no" votes to sink the bill.
Democrats have made clear they will unanimously oppose the bill. "Trumpcare is just a breathtakingly irresponsible piece of legislation that would endanger the health of tens of millions of Americans and break the bank for millions more," said Senate Minority Leader Chuck Schumer, D-N.Y.
And Republicans in the Senate have their own internal disagreements, too.
Here are five of the biggest flashpoints that could make trouble for the bill in the Senate.
House leaders correctly point out that their bill represents the biggest changes to the federal-state health program for the poor since its inception in 1965 — a point that appeared to be drowned out during the most recent House debate that focused on coverage for people with pre-existing health conditions.
For the first time, federal funding for low-income people on Medicaid would be limited, resulting in what House Speaker Paul Ryan, R-Wis., described at an event sponsored by the conservative National Review as "sending it back to the states, capping its growth rates." It's a longtime goal for many conservatives. "We've been dreaming of this since I've been around," Ryan said.
But it is not a consensus position in the party. Some moderates support the current program, especially for children and people with disabilities. In addition, many GOP governors took the federal government's offer in the ACA of near-complete federal funding to expand Medicaid to nondisabled, working-age adults, and they are worried about the impact on their residents and their budgets if the expansion goes away and the program's funding is restricted.
The House bill, wrote the Republican governors of Ohio, Michigan, Arkansas and Nevada in a letter to House and Senate leaders, "provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states."
That pushback has also created doubts in the minds of some GOP senators. Rob Portman, R-Ohio; Bill Cassidy, R-La.; and Shelley Moore Capito, R-W.Va., are among those who have expressed concerns about the House bill, as has Dean Heller, R-Nev., It's not clear whether any of the House changes have satisfied those senators.
Increase in number of uninsured people
The Congressional Budget Office's initial estimate that the bill could lead to 24 million more Americans without health insurance within a decade spooked many Senate lawmakers. "You can't sugarcoat it," Cassidy told Fox News when explaining that "it's an awful score." The final House bill passed without the score being updated, although most outside analysts said the changes were likely to increase the number who would lose insurance.
And Democrats have been using those initial numbers to score rhetorical points, even if they lack the votes in either the House or the Senate to stop the bill or change it.
"The CBO's estimate makes clear that Trumpcare will cause serious harm to millions of American families," said Schumer. "Tens of millions will lose their coverage, and millions more, particularly seniors, will have to pay more for health care."
On one hand, even with the additional $85 billion added by House leaders to help older people pay for their insurance premiums, many moderates feel the age-based tax credits in the bill replacing those in the Affordable Care Act are too small, particularly for people in their 50s and early 60s. The CBO estimated that under the original version of the House bill, premiums for a 64-year-old with an income of $26,000 a year could rise from $1,700 currently to more than $14,000.
That brought a strong rebuke from the powerful AARP, which was an outspoken ACA supporter. "Although no one believes the current health care system is perfect, this harmful legislation would make health care less secure and less affordable," said a statement from the group.
Sen. Susan Collins, R-Maine, has said she could not support the House bill in its original form because of concerns about the effects on older constituents.
On the other hand, some conservatives in the Senate are ideologically opposed to offering any tax credits. Ted Cruz, R-Texas; Mike Lee, R-Utah; and Rand Paul, R-Ky., have all expressed concerns about the bill being too much like the ACA, with Paul referring to it as "Obamacare Lite." They worry that the tax credits amount to a new entitlement.
"For me, it's a big stumbling block still that there's taxpayer money that's being given to insurance companies," Paul told reporters in late April. "And I'm just not in favor of taxpayer money going to insurance companies."
As Republicans have been vowing for years, the House-passed bill would defund Planned Parenthood, although only for a year. That's likely because a permanent defunding would actually cost the federal government more money, according to the CBO, as some women who lose access to birth control would become pregnant, have babies and qualify for Medicaid. Birth control is vastly cheaper than health care for mothers and babies.
But while cutting funding for Planned Parenthood is overwhelmingly popular in the House, there are a handful of GOP senators, including Collins and Lisa Murkowski, R-Alaska, who have said they are likely to oppose a bill carrying this provision.
The budget process Republicans are using to avoid a Democratic filibuster in the Senate, called reconciliation, has very strict rules that require every piece of the bill to be directly related to the federal budget. It will be up to the Senate parliamentarian, a Republican appointee, to make those determinations.
That's why the bill does not wipe away all the ACA's private insurance regulations, including the requirement that insurers not discriminate against customers who have pre-existing health conditions.
Some analysts have suggested that the House amendment sought by conservatives to allow states to waive some of the health law's regulations might run afoul of the Senate's "Byrd Rule," which limits what can be included in a budget reconciliation measure.
Even Rep. Mark Meadows, R-N.C., who negotiated that amendment that won the backing of conservatives, conceded that it could prove problematic in the Senate. "There's still a lot of work that needs to be done before we can celebrate and all go home," he said in an interview outside the House chamber.
Democrats say it is one of several provisions in the House bill that might not pass parliamentary muster in the Senate.
For example, analysts have suggested that the GOP replacement for the much disliked "individual mandate" requiring most people to have insurance or pay a fine might not pass Byrd Rule scrutiny either. That's because the 30 percent premium penalty that people with a lapse in insurance would have to pay under the bill would go to the insurance company, not the federal government, so it would have no budget impact.
A third potentially problematic element of the original House bill would allow insurers to charge older adults five times more in premiums than younger adults — up from a ratio of 3 to 1 under the Affordable Care Act. That provision could be viewed as not directly affecting federal spending, some analysts predict.
LAKSHMI SINGH, HOST:
We're returning stateside now to talk about the future of health care in the United States. Weeks after failing to muster enough GOP support in the U.S. House, the American Health Care Act has narrowly passed in that chamber on a vote of 217 to 213. Now it heads to the Senate, but this time Republicans passed the bill without knowing what it would cost. It's a special analysis that gets done on every piece of legislation by the nonpartisan watchdog arm of Congress called the Congressional Budget Office.
And when it comes to passing major changes to health care, the price tag matters a lot to some lawmakers. So this week, our Words You'll Hear are CBO score, which we expect will be in the news in the coming weeks as the Senate prepares to take up the House bill. With me is Julie Rovner. She is the chief Washington correspondent for Kaiser Health News. Julie Rovner, thank you so much for joining me.
JULIE ROVNER: My pleasure.
SINGH: Before we get into what the Senate could do, help us understand. The initial estimates said the bill could lead to 24 million Americans losing health insurance. What are you looking to learn with this score and why is it such a big deal?
ROVNER: Well, yeah, there's two very important things when the Congressional Budget Office scores a bill like this that changes people's health insurance coverage. You want to know obviously how much it's going to cost or how much it's going to save. But you also want to know what it's going to do to people's coverage. And in this case, the first version of the bill which was not the version that passed, the Congressional Budget Office estimated that up to 24 million people could be without coverage after 10 years.
That's a combination of people who would lose their coverage through Medicaid, people who would lose their coverage because they'd no longer be able to afford it in the individual market. And some people, as Republicans point out, who would not have coverage because they're now being required to buy it and they would no longer be required to buy it.
SINGH: Julie, walk us through the key policies in the current legislation that you think will encounter problems in the Senate.
ROVNER: There are a lot of them. I think the first one is the Medicaid program. That's a program for people with low incomes. The House bill - as has been widely reported - would phase out the expansion of Medicaid that was in the Affordable Care Act. But what has been less widely reported is that it would also put a cap on the overall program, not just the expansion, but all of Medicaid.
This is something that Republicans have been agitating for for some decades now. It has never passed because governors, including Republican governors, tend not to want less money from the federal government. But that's one of the main things that the CBO said could lead to people losing their coverage, and that's not just people who got it in the expansion, but that's low-income women and children and elderly and disabled people because states would not be able to keep up with the amount of inflation in the Medicaid program.
SINGH: Do you recall generally just how many people would be affected by that particular problem?
ROVNER: Well, the Congressional Budget Office says that about 14 million of the 24 million people who could lose coverage would lose it through the Medicaid program.
SINGH: Julie, are there any other policies that we could see running into problems as a result of this legislation?
ROVNER: Yes. I think the way the House changes the tax credits that help people get to pay their premiums. There are senators from states where health insurance costs a lot more who are very concerned that the new subsidies of the tax credits wouldn't go far enough to help people in their states, and that's going to divide more geographically than it is going to really divide by party.
SINGH: What are the different political factions in the Senate that could prove especially tricky for Republicans in the Trump administration?
ROVNER: Well, the Senate has only 52 Republican votes. It's a very narrow majority. So they're going to have to sort of walk this tightrope. There's four or five moderates and four or five conservatives who could peel off depending on what they do with the bill. As I mentioned with Medicaid, you've already got four or five members from states who - states did expand the Medicaid program - who are very uncomfortable with the Medicaid cut.
You've got some conservatives who would be very uncomfortable if it didn't have the Medicaid cuts, you've got a one year defunding of Planned Parenthood - again, very important to some of the conservatives, very important not to have in it from some of the moderates. So it's going to be extremely difficult to get a bill through the Senate that's going to get the 50 votes they need. They - Vice President Mike Pence could break a tie. So they would need at least 50.
SINGH: We expect that the Senate will probably be working on this bill for a long time. So what are the next steps that we can expect to see?
ROVNER: Well, the next thing we could see is we started with at the top is a full Congressional Budget Office score of the bill as it passed the House, which didn't happen before the House passed it. The Senate has a 13-member working group that's trying to work something out.
One of the important things to remember is that because of the budget process that they're using to do this bill where they only need a simple majority in the Senate, rather than 60 votes, they can't start tax reform until they finish health care because they would need to do another budget resolution. And as soon as they did the next budget resolution, the health care protections would go away. So the longer they take on health care, the longer it is before they can even start on taxes.
SINGH: That's Julie Rovner. She's the chief Washington correspondent for Kaiser Health News. Julie, thank you for your time.
ROVNER: Always. Transcript provided by NPR, Copyright NPR.