It took blood, sweat and tears for Republican leaders to finally push their health care bill through the House last week. Don't expect the process to be less arduous in the Senate, though more of the angst in that more decorous chamber will likely be behind closed doors.
No one expects a new bill to be written quickly, but Senate Majority Leader Mitch McConnell, R-Ky., has started a process for producing one. Republican senators have made clear their measure will differ markedly from the House legislation, which has drawn withering criticism from Democrats who see it as a pathway to winning a House majority in the 2018 elections.
"This process will not be quick or simple or easy, but it must be done," McConnell said Monday.
MCCONNELL'S WORKING GROUP
McConnell dislikes surprises and drama. Both characterized the House's chaotic four months of work on its bill, which saw revolts by conservatives and moderates derail initial versions and humiliate President Donald Trump and Speaker Paul Ryan, R-Wis.
McConnell has included himself in a group of 12 GOP senators essentially tasked with privately producing a bill that can pass the Senate. Republicans control the chamber 52-48.
Democrats are virtually certain to unanimously oppose the Republican effort to repeal much of President Barack Obama's health care overhaul. So Republicans are using a special process preventing a Democratic filibuster that would require 60 votes to end. McConnell will need 50 GOP votes to pass a bill, a tie Vice President Mike Pence could break.
That means McConnell can lose just two Republicans, so his group has a strategically shaped membership.
THE GROUP'S ROSTER
Sens. Lamar Alexander, R-Tenn., Mike Enzi, R-Idaho, and Orrin Hatch, R-Utah, chair pivotal committees. Sens. Rob Portman, R-Ohio, and Cory Gardner, R-Colo., are from states that used Obama's law to add hundreds of thousands of beneficiaries to Medicaid, an expansion they want to protect but the House bill would end. Gardner chairs the Senate GOP's campaign committee.
Sens. Ted Cruz, R-Texas, and Mike Lee, R-Utah, are conservative firebrands who represent states that didn't expand Medicaid but want additional funds for that program. Sens. John Cornyn, R-Texas, John Thune, R-S.D., and John Barrasso, R-Wyo., are in the Senate GOP leadership, and Tom Cotton, R-Ark., is an ambitious up-and-comer who frequently criticizes the House measure.
Democrats and liberal activists have lambasted McConnell for appointing a group with no female members.
Portman is among Republicans whose states dislike the House's Medicaid cuts because they'd face a wave of constituents losing coverage under the health care program for the poor. The House would end the extra federal money states get for new beneficiaries under Obama's Medicaid expansion by 2020, and some GOP senators want a delay.
Much Medicaid money is used to combat the illegal use of addictive opioid drugs. That's another reason for GOP senators from hard-hit Midwestern and Northeastern states to oppose such cuts.
Obama's law helps millions buy private insurance with federal subsidies geared to income and policy premiums. The House instead links its aid to age, with older people getting larger tax credits. Thune and others want to shift the subsidies more generous to lower earners.
Cruz said House conservatives won "a positive improvement" with provisions letting states get federal waivers so insurers can charge some people with pre-existing conditions higher premiums, and letting states decide which medical services insurers must cover. He said "considerably more work" was needed to lower premiums.
In addition, the filibuster-free process Republicans are using requires that legislative provisions be related to raising or decreasing the federal deficit, and not primarily driven by policy changes. Conservative health care analyst James Capretta says the odds for survival "are low" for House language allowing state waivers for higher premiums on people with pre-existing conditions.
Also in jeopardy: a provision forbidding consumers to use federal subsidies to buy insurance covering abortion.
The Senate parliamentarian will decide whether provisions must be stricken from the bill. The Senate could override that with 60 votes.
The pro-Democratic group Save Our Care is running ads in 24 districts whose GOP House members backed the bill asking, "How could you do this to us?" Obama urged lawmakers to use "courage" to protect health care for poorer Americans, a rare public comment on public policy since leaving office.
Underscoring political sensitivities, critics attacked Rep. Raul Labrador, R-Idaho, for saying at a town hall meeting that "nobody dies" from lack of health care. He later said that "wasn't very elegant."
Republicans are advertising too. The American Action Network, with links to House GOP leaders, is advertising nationally and in Ryan's district promoting the bill.
Sen. Bill Cassidy, R-La., was set to appear on ABC's "Jimmy Kimmel Live" after saying any GOP bill must pass "the Jimmy Kimmel test." The talk show host last week delivered a tearful monologue describing life-saving heart surgery his newborn son had received and saying lawmakers must help people afford health care.
The nonpartisan Congressional Budget Office is expected to release its analysis of the House bill this month. It projected an earlier version would toss 24 million people off health coverage, a damaging blow that made it harder for House Republicans to pass their bill.
No one is certain when the Senate might approve its bill, though some following the process think that could come by July 4.