Main Challenges Facing Senate Repeal of ACA by Luke Perry
The House passed a repeal of The Affordable Care Act by a vote of 217 to 213. 20 Republicans and all Democrats opposed the bill. The big political question is now: will the bill pass the Senate? This will be difficult for four main reasons.
ONE: The Congressional Budget Office (CBO), the nonpartisan evaluator of proposed legislation, has yet to score the bill. As a result, the total cost and health insurance implications, including how many people would lose insurance, has yet to be assessed. Once completed this will influence the debate and likely be a challenge for Republicans. The CBO score surrounding the initial House effort to pass The American Healthcare Act was damaging for Republicans precisely because of the cost and the twenty million people who would have lost their insurance.
TWO: Republicans decided to not work with Democrats on healthcare reform, so their margin of error in the Senate is very small. The Republicans currently hold 52 seats. They need 60 votes to overcome a filibuster, requiring all their members and eight Democrats to be on board. If they pass at least some of the bill through reconciliation (a special budget measure that cannot be filibustered), then just 50 votes (plus the U.S. Vice President) is necessary. That would still be difficult.
Eight GOP Senators did not support Donald Trump during the 2016 campaign: Ben Sasse (NE), Jeff Flake (AZ), John McCain (AZ), Susan Collins (ME), Lisa Murkowski (AL), Rob Portman (OH), Lindsey Graham (SC) and Rand Paul (KY). Many of these Senators have been critical of President Trump’s policy, personnel, and his personal conduct. They will be among leading skeptics of the House bill. Senator Paul, for instance, assumed this role weeks ago.
THREE: The norms of the Senate are different than the House. The Senate is the more deliberative chamber designed to temper the popular passions of the House. They will likely move more slowly and more deeply examine the implications of the legislation than the House.
House members are more concerned about reelection (all members are up for reelection every two years) and public perceptions surrounding their party, so they are more easily influenced by electoral considerations and leadership. Senators are more independent. Two thirds of the chamber are not up for reelection next year. They are less concerned about electoral consequences and being “whipped” by party leaders.
FOUR: The Affordable Care Act (ACA or Obamacare) has never been more popular. As of last month a majority of Americans support ACA (55 percent) for the first time in its existence, while only 30 percent wanted it repealed. Conversely, The American Healthcare Act has never been popular. 56 percent disproved of it March when the GOP twice decided to delay a vote, including 1 in 4 Republicans.
Popularity is important in national policy making, but not determinative. Congress makes unpopular decisions and fails to act legislatively even with overwhelming public support. At the same time, a significant portion of Americans are uninformed about the bill. For example, 1 in 3 Americans don’t know or aren’t sure if Obamacare and ACA are the same law.
All politics is local, even national politics. What will be interesting to see is the extent to which members of Congress vote with or against the will of their constituents. In the House, for example, 23 GOP House members represent districts Hillary Clinton won in 2016. 14 of those members voted for the bill. The Democrats believe that makes their candidates competitive in those districts, even singing goodbye on the House floor after the vote. (Who thought C-SPAN could be so entertaining?)
Here are three things to look for in the weeks ahead:
FIRST: What changes will the Senate make to the bill? Most analysts believe significant ones are necessary to secure passage. Some, such as Senator Lamar
Alexander (R-TN), have already made clear they’re “writing a Senate bill and not passing the House bill.” That is not an encouraging sign for Republicans.
SECOND: How much more moderate will Senate Republicans be than their House counterparts? Representing a predominately rural district in Ohio is different than representing all of Ohio, including more liberal cities, as Senator Portman knows. Moreover, Senators from less conservative states, such as Senator Collins, are generally less inclined to support the House bill. How this influences the legislative process will be crucial.
THIRD: I’ve previously argued the legislative filibuster is all but dead. President Trump recently supported doing away with it, though Senate Majority Leader McConnell rejected this suggestion. It will be interesting to see whose vision wins out should the legislative process lead to standoff surrounding a filibuster.
Luke Perry (@PolSciLukePerry) is Professor of Government at Utica College.