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The risky, improbable, possibly only way for Republicans to actually repeal Obamacare

“Take it or leave it.”

Alex Wong / Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Republicans might have only one hope for delivering on their promise to repeal and replace Obamacare: Pray the Senate passes a bill and then, whatever that bill is, force the House to pass it too.

It’s not a foolproof plan, and it’s sure to rankle some lawmakers in the House. But it might be the best of the GOP’s bad options, as the party has struggled to roll back the hated health care law so far.

“I think the (unstated for obvious reasons) plan all along has been for [the] Senate to pass a bill and for McConnell to say to the House: ‘Take it or leave it, but this is the best bill that could get 50 votes over here,’” one Republican health care lobbyist said, on condition of anonymity. “The House may or may not accept that, but that's how this will go — no conference.”

The House barely squeaked through a bastardized bill in early May, after coming up embarrassingly short on votes a month earlier. Now Senate Republicans are staring at some equally tough math and big policy divisions within their ranks as they write their own plan. If the Senate does find a path through the policy thicket and passes a bill, Republicans have two options.

The House and Senate could go into conference negotiations and come up with a compromise bill that both chambers would then have to pass again. That path promises weeks of difficult negotiations, with no promise of success, and another tough vote for lawmakers if a compromise is found. The Senate’s internal talks are expected to push into August; further deliberations between the two chambers would delay the rest of the legislative agenda — including a tax overhaul — even later into the year.

Republicans don’t want to drag this out any more than they have to. The political repercussions of the projected coverage losses under the House bill (23 million) are already haunting vulnerable House members. That figure is also giving senators pause about passing anything that too closely resembles the House’s American Health Care Act.

Which is why you’re starting to hear whispers that if the Senate somehow clears a health care bill, GOP leaders would take the second, quicker path to get the legislation through Congress and in front of Trump.

“I think in the end — and again, who knows how this ultimately ends up — if we move a bill through the Senate that the House thinks it could take up, maybe it goes back over there and they have a vote on it, see whether or not they can pass whatever it is the traffic will bear in the Senate,” Sen. John Thune (R-SD), the No. 3 Republican in the Senate, told reporters last week.

“Or we pass something here and we go to conference with them and try to work the differences out,” he continued. “I don’t think any decision’s been made from a strategy standpoint. But we know that it’s a delicate balance.”

Thune was being diplomatic. But GOP lobbyists and congressional aides think the Senate would undoubtedly prefer the first option.

That option has some strong arguments in its favor. Yes, the House struggled to pass its plan. But it still has a far bigger margin of error — Republicans can lose 20-plus votes and still pass a bill — than does the Senate, where they can lose only two members, under the procedural rules they’re using to pass the bill with just a bare majority of 50.

Between that slim path and the complex rules that restrict what the Senate can include in its bill, Senate Republicans could argue that the House has no choice but to accept their legislation.

That strategy would, however, depend on House Republicans — particularly the archconservative Freedom Caucus, which helped derail the House bill the first time — being willing to go along with it. It took a lot for those on the far right in the House to get to “yes.” They might be reluctant to simply swallow whatever the Senate sends them.

Rep. Mark Meadows (R-NC), who chairs the Freedom Caucus, told reporters earlier this month that he had been meeting with senators about what they might change in the bill, even helping to draft amendments. He sounded upbeat that the legislation coming out of the Senate would be something his members would accept.

“It will be revised,” Meadows acknowledged. “I’m not as concerned about it getting it changed as I am about trying to make it better.”

But there are some existential issues in play in the Senate. If the Senate defunds Planned Parenthood, as the House bill did, they will almost assuredly lose two votes — Sens. Susan Collins (R-ME) and Lisa Murkowski (R-AK) — giving leadership absolutely no room to lose any other votes. They’d have to run the table.

But if the Senate bill keeps Planned Parenthood funding to appease those senators, Meadows signaled that would be a nonstarter for him and other conservatives in the House.

Then there are the waivers in the AHCA, a concession that the Freedom Caucus won that allows states to opt out of some Obamacare insurance regulations. Those waivers may not comply with the Senate’s procedural rules, which are supposed to limit the bill to provisions that affect federal spending or revenue.

Even if the waivers are permissible, they might not have the votes to pass.

“I support having the preexisting conditions [protections] as part of the Senate bill,” Sen. Dan Sullivan (R-AK), another key swing vote, told reporters last week. “No waivers.”

Perhaps with that in mind, some House members have already made their own counterargument to Senate Republicans: Look how hard it was for us to pass a bill. You can’t mess with our plan too much or the whole thing might fall apart.

“I just think if [senators] have eyes to see how tight this thing is,” Rep. Dave Brat (R-VA) said, “if they change more than a iota — they know what they are doing, they are rational, they see what it was like to get to the sweet spot here. Any big changes, I don’t think it will go over too well.”

Tara Golshan contributed reporting.