[Update] Okay, NOW What The Heck Is Going On With Senate Obamacare Replacement Bill?

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Healthcare is the shambling zombie bill that simply will not stay dead. First the Senate was going to have a vote on a plan to repeal and replace the Affordable Care Act; then it wasn’t. Then the Senate was considering a new proposal; then it wasn’t. Now, there is a vote on a bill tentatively planned for tomorrow, July 25 — but if it seems like nobody actually knows what’s in it, or who supports it, or what’s going on, well, that’s because basically nobody does.

So here’s what we do know.

What’s happened so far?

The House passed its repeal-and-replace plan, the Affordable Health Care Act (AHCA), in a narrow 217-213 vote in early May. After that, the Senate’s turn began.

In recent weeks, however, the Senate’s action on healthcare has been madcap at best. The process from the start was largely conducted in secret, leaving everyone else to piece it together from leaks and educated guesses. Eventually, a draft version of the Senate’s plan, the Better Care Reconciliation Act (BCRA), became public. Here’s a timeline of what’s happened since then:

June 22: Senate Majority Leader Mitch McConnell (KY) releases draft text of the BCRA.

June 23: After getting a look at the text, hospital, doctor, and public health groups nationwide oppose the bill, saying it makes “unsustainable” cuts to coverage.

June 26: The Congressional Budget Office (CBO) comes up with a preliminary score for the BCRA, finding that the bill would likely cause 22 million more Americans to become uninsured than currently are.

June 27: Unable to come to consensus before the July 4 recess, the Senate postpones the vote on the BCRA until July.

July 13: The Senate introduces a new, second draft of the bill, including language that will functionally restore pre-existing condition exclusions to millions of Americans as well as cut Medicaid.

July 14: The health insurance industry itself pens a letter to the Senate saying that its proposal is bad news, calling it “inadequate” and saying that millions will lose coverage.

July 15: Sen. John McCain (AZ) announces that he will be absent from the Senate for at least one week due to a health issue; in response McConnell delays a procedural vote planned for July 18.

July 18: Having determined that the BCRA can’t pass as-is, McConnell instead suggests the Senate should vote on a straight repeal-only measure. Out of the gate, “repeal-only” already has three detractors, seemingly rendering it doomed.

July 19: The CBO finds that a straight-up ACA repeal would cause an additional 32 million Americans to lose access to health insurance.

July 20: President Trump hosts the Republican members of the Senate for lunch and encourages them to vote in favor of a repeal bill, despite its unpopularity and the indefinite absense of Arizona Sen. John McCain, recently diagnosed with a brain tumor. McConnell indicates that he plans for a vote on July 25.

July 21: The Senate Parliamentarian (the person in charge of making sure the Senate follows all the Senate rules) determines that many of the provisions of the BCRA fall outside the scope of what is allowed by a budget resolution.

What are they voting to do?

The vote, tentatively scheduled for the morning of Tuesday, July 25, isn’t actually a vote on the bill itself. Even if it manages to muster 51 votes, it won’t immediately become something that heads up to the White House for a presidential signature.

Instead, the vote is called a Motion to Proceed (MTP). That means basically what it sounds like: If the motion carries, then the Senate proceeds with debate on the bill.

The Brookings Institution has a deep-dive explainer on the Senate’s procedures with a budget resolution, for those who are interested.

The important highlights are that the Senate will need a simple majority — 51 votes — to proceed, and that McConnell can move forward with a “full text substitute” rather than an actual full bill.

If the Senate does vote to proceed, that opens up a 20-hour window of debate, during which point a massive number of amendments can be suggested and rapidly voted on. This period is called the “vote-a-rama,” and if that’s what we end up with, it will indeed seem like a chaotic marathon of suggestions, possibly stretching through the night.

But that “full text substitute” is super important, because…

Nobody actually knows what text the Senate is voting on.

Nobody is entirely sure. At least, nobody who is sure is speaking publicly about it.

Because McConnell can introduce a full text substitute, there are many possibilities for what he might ask his fellow Senators to vote on. It could be:

  • The AHCA that the House passed
  • The first version of the BCRA
  • The second version of the BCRA
  • A version of the ACA repeal bill that the Senate passed in 2015
  • Or something else we haven’t seen yet

As of today, Senate Republicans still don’t know which text they will be asked to consider on Tuesday, the Wall Street Journal and others report.

Where do they stand?

In order to proceed, McConnell needs 50 Republican Senators to vote in favor, plus a tie-breaking 51st vote from Vice President Mike Pence. There are 52 Republicans in the Senate, so if more than two are absent, or vote no, the motion cannot proceed.

Politico reports that Republican lawmakers are pre-emptively treating the July 25 vote as doomed, assuming that both Collins and Murkowski are still against it. But who’s against it, and who swings around to being in favor, depends entirely on what proposal the Senate actually ends up voting on.

The cluster of Republican Senators who spoke out against either the BCRA or the repeal-only plan included both hardline conservatives as well as their more moderate counterparts. Sens. Susan Collins (ME) and Rand Paul (KY) were firmly against the BCRA, for different reasons, and were eventually joined by Sens. Mike Lee (UT) and Jerry Moran (KS).

When McConnell then suggested voting on a straight repeal, he drew opposition once again from Collins, this time joined by Sens. Shelley Moore Capito (WV) and Lisa Murkowski (AK).

Due to his recent diagnosis and health care issues, Sen. McCain is not expected to return to D.C. this week. That means if the Senate votes on July 25, McConnell can only afford one Senator peeling off, not two.

Collins appears to be still a firm “no” for whatever the Senate does actually vote on in the end, meaning that if McConnell is to succeed, she can be the only one not to vote in favor.

Paul, meanwhile, has since said that if the Senate votes to move forward with a repeal bill, he will be a yes on the motion to proceed.

Sens. Capito, Heller, Lee, Moran, Murkowski, and Portman are still entirely up in the air as well. Whether or not they will support the measure depends on what measure ends up in front of them, and what amendments McConnell promises can follow in the vote-a-rama.

President Trump is himself with Capito in West Virginia today, both to encourage her to vote in favor of a motion to proceed, and also to give a speech on health care encouraging all Republican Senators to vote in favor of the measure, whatever it actually is.

In his remarks, Trump led by saying that “for the past 17 years,” the ACA, which was passed in 2010 and most provisions of which took effect in 2014, “has wreaked havoc on the lives of innocent, hardworking Americans.”

Trump then chided the Senate Republicans, saying, they “have not done their job in ending the Obamacare nightmare,” and exhorted them to “repeal and replace” the ACA.

What happens next?

In a broad sense, there are three possible outcomes this week.

  1. The Senate votes on the measure; it garners 50 or fewer votes and fails to proceed.
  2. The Senate votes on the measure; it gains 51 or more votes and proceeds.
  3. The Senate once again postpones or decides not to vote on the measure.

If the motion to proceed succeeds, Senators will discuss and negotiate on a whole pile of amendments to try and cobble together a bill. Formally, the Senate then gets its 20 hours of debate, which becomes an all-night vote-a-rama until, as CNN estimates, 4:00 or 5:00 in the morning at which point they are done.

If the motion to proceed fails, however, Senators can either work together to craft a new proposal and try again, or decide that this process is too much of a mess and come back to it later, never, or in an entirely different way (like by introducing a bill that isn’t a budget reconciliation measure).

As to the details, Vox has a handy flowchart outlining the possibilities from here.

Sen. McCain announced late into the evening on July 24 that he will be returning to Washington, D.C. for the vote on July 25, health notwithstanding. That significantly increases the chances of a motion to proceed — on whatever bill McConnell holds it on — succeeding.

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