Senate leaders, led by Majority Leader Mitch McConnell (R-KY), have set an ambitious timeline for consideration of that chamber’s version of health care legislation, after the House passed its version on May 4th. On June 30th, Congress leaves for a week-long recess and the July 4th holiday, and Leader McConnell’s goal is to pass a bill before that break. Water cooler conversation around D.C. health policy circles is nearly all focused on whether they can meet that mark.

With tight deadlines in place and a very tight margin for error (the GOP majority can only afford to lose two of its members, should all Democrats vote no) Senate leaders have been playing a game of three-dimensional chess to fashion a bill that can pass the chamber. While the process has proceeded largely out of public view (something for which leaders have been criticized), a broad sense of the direction and the major sticking points is starting to emerge. Based on what we’re hearing, the following issues are still under discussion:

• Medicaid. Much more so than in the House, Senators have waded deep into the weeds of Medicaid reforms. Senators representing states which expanded Medicaid under the ACA have expressed concern about the House’s rollback of the expansion, though by and large appear to be advocating for a slower “phase out” of the expansion funds, rather than for keeping it altogether. Discussions have ranged from a three-year to a seven-year so-called “glide path” for lowering federal funding for the expansion. More conservative Senators are arguing that the growth rate in the Medicaid “per-capita cap” included in the House bill was too generous, and that more money could be saved by lowering that rate. Debates are ongoing about if any additional areas should be “carved out” from states’ calculations of the cap, as well as how the “base year” (or the starting point for cap calculations) should be set.
• Tax Credits. The House bill would replace the ACA system of income-based subsidies for the purchase of private insurance with a new tax credit system based instead on a beneficiary’s age. However, the Congressional Budget Office analysis of the House bill found that it would be difficult for these tax credits to cover the cost of care – the CBO estimates the credits would be particularly insufficient for low-income, rural, elderly patients. Multiple Senators have focused their efforts on making the tax credits more generous, especially for this particularly vulnerable group of patients.
• Taxes. Both categories of changes outlined above, for the most part, are costly to change, especially if Senate leaders aim to appease more moderate members by making the bill more generous. Because Senate rules dictate that the Senate’s bill cannot spend more (or in this case, save less) than the House bill, Senators will need to find a way to pay for these changes. The main avenue discussed has been to change the House provisions when it comes to repealing taxes instituted by the ACA. Some of these tax cuts could come out of the bill altogether, and some could be “pushed out” to take effect further into the future. However, conservative Senators (and now some House members too) are weighing in with concerns about anything less than full repeal of the ACA taxes.
• Insurance Regulations. After collapsing in March due to a lack of support, the effort to pass the House health care bill was revived by several amendments. One of these, the so-called MacArthur amendment, allowed states to waive certain consumer protections put in place by the ACA, including the prohibition on plans charging sick patients more, and the “essential health benefits” plans are required to cover. Questions remain over whether the MacArthur amendment would be permissible under Senate procedural rules, which require that all provisions of the bill be budget-related, not policy-related.

These are by no means the only issues on the table, but represent some of the big categories shaping the tightrope Senate leaders must walk to pass a bill. NACHC has expressed our concern with several aspects of the House-passed legislation, in particular those provisions related to Medicaid, and the effect these changes would have on health centers and those we serve. Working in tandem with state and regional primary care associations, health centers, and other national partners, we continue to engage with all parties in the Senate to improve the legislation. You can take action too – click here to weigh in with your Senators at this critical moment.