The Senate's 4 big problems with health care

Republicans are running way behind schedule.

In the dream scenario outlined by party leaders back in January, President Trump would have signed legislation to repeal and replace the Affordable Care Act, also known as Obamacare, months ago. By early June, Republicans were supposed to be in the thick of overhauling the tax code.

Here's the reality: The GOP health care debate is stalled in Congress, and its uncertainty has clogged up the legislative pipeline to Trump's desk. Republicans can't move on — and many are ready to do so — until they resolve the fate of their long-promised health care bill.

Here are four big problems standing in the way.

1. Lack of momentum "I don't see a comprehensive health care plan this year," Sen. Richard Burr, R-N.C., told a local TV station on Thursday.

Nearly a month after the House passed its version of the health care bill, 13 GOP senators have had weeks of closed-door meetings but so far have failed to produce any discernible progress on health care. The one piece of consensus is that the House-passed American Health Care Act is a non-starter in the Senate.

Senate Majority Leader Mitch McConnell, R-Ky., was candid about the bill's status in an interview with Reuters before the Memorial Day break. "I don't know how we get to 50 [votes] at the moment. But that is the goal. And exactly what the composition of that [bill] is I'm not going to speculate about because it serves no purpose," McConnell said.

McConnell has little room for error. With a 52-seat majority, he can only lose two votes and pass a health care bill, with Vice President Pence as a tiebreaker. But warring factions of Senate Republicans remain sharply divided on their priorities.

2. Policy disagreements Conservatives like Sens. Ted Cruz of Texas and Mike Lee of Utah say they can't support any legislation that won't demonstrably lower premium costs. To that end, they have floated a proposal to repeal the ACA's insurance regulations or to let states opt in to the ACA's standards. Those regulations include protections for people with pre-existing conditions and mandates on what services insurance plans have to cover on the individual market — the "essential health benefits" that became a big part of the debate in the House this spring. In sum, the proposal would allow for plans that are less expensive, mainly by allowing people to attain less coverage.

But doing so would likely lose the votes of more centrist Republican senators, like Susan Collins of Maine and Bill Cassidy of Louisiana. That duo has been working on their own legislation that would allow states to keep Obamacare intact and more broadly keep popular parts of the bill in place. But their proposal alienates conservatives who have derided it as "Obamacare-lite."

There are also divisions among Senate Republicans from states that took the Medicaid expansion with federal funding and those from states that rejected that money. One key issue is how, and how long, to let states keep the expansion in place or to create a timeline to wind it down.

3. Rules not meant to be broken All of this is happening in a chamber with much more restrictive rules on what can be included in the bill than in the House. Republicans are producing a health care bill under "reconciliation" — the budget process to allow legislation to pass with 51 votes in the Senate instead of 60, eliminating the need to get any Democrats on board. One issue is that the House bill included language that prevents individuals from using tax credits to purchase insurance plans that cover abortion services. This provision is unlikely to pass the Senate's "Byrd Rule," which aims to block senators from using this fiscal process to include policies unrelated to taming the deficit.

While a vote is not in sight, multiple aides close to the negotiations say that senators are acting in good faith and that everyone wants to get to "yes" on a bill — they just have no idea what that bill looks like. How to craft a bill that can win over warring factions and pass procedural hurdles is a question without an answer.

4. A ticking clock

The pressure to act — or move on — is building. The reconciliation protections to pass health care with 51 Senate votes expire at the end of September — but senators and aides are operating under an assumption that if there is no bill by the August break, then hopes for health care legislation have likely tanked.

June could be a make-or-break month for the bill because, if the Senate has to negotiate a final bill with the House, it will likely need to be close to a deal by the July Fourth recess — just four weeks from now.

Health care is also holding up the rest of the agenda. Congress can't move on to next year's budget resolution — which sets up the framework for tax reform — until health care is complete, because of congressional rules.

On top of that, Treasury Secretary Steven Mnuchin has already asked Congress to vote to lift the debt ceiling before lawmakers go home for the month of August, setting up a partisan fight over spending.

Congress also needs to start work on spending bills to fund the government for the next fiscal year. If legislators go home for the August recess, they will only have four weeks in September until the 2018 fiscal year begins, at which point the government runs out of funding unless Congress does something to supply more money on a short- or long-term basis.

The motivation to act on health care is driven in part by the political discomfort over the party's failure to hand Trump any major legislative victories as Congress approaches the 2017 halfway mark. But if there is no fresh progress as talks roll on into June, the motivation may shift toward winnable legislative battles. Copyright 2019 NPR. To see more, visit https://www.npr.org.