As work commences on a health care bill in the U.S. Senate today, the Capitol Hill veteran of 30 years offers his insight into the challenges that lie ahead for Republicans on Capitol Hill:
In a most eventful week last week, Congress passed a bill to fund the appropriations for the rest of fiscal year 2017, and the House passed the first step to health care reform.
Many of the spending and language issues were avoided in reaching bipartisan agreement on the appropriations funding bill. When September comes around it could well be a different story. This could mean a much bigger fight on funding for the wall, more money to rebuild the U.S. defense posture, and legislative riders of all sorts. Because of the work on the reconciliation bill and the delayed appropriations process for FY 17, Congress is very late in beginning the budget and appropriations process for FY18. More on that later.
When the vote on the repeal and replace legislation was postponed in March there were some who said that it would die. Indeed, reports of its death were greatly exaggerated. Behind the scenes work never stopped. Congressmen Tom MacArthur and Mark Meadows undertook discussions on an idea developed by MacArthur that resulted in convincing most of the Freedom Caucus members - and a few from other groups - to support the health care legislation. A final addition by Congressmen Billy Long and Fred Upton brought together the final votes needed to pass the reconciliation bill.
This legislation now goes to the Senate. It will not be taken up immediately - or at all. Majority Leader McConnell is convening a cross-section of Republican Senators to review the House bill and develop a Senate proposal before the reconciliation bill is brought to the floor in the Senate. Just as it did in the House, this will take time and patience and some give among all Republican Senators.
There are many changes that the Senate will focus on as they review the House legislation. One of the most significant will be Medicaid reform. This was not a topic of much discussion in the House. That is because there was little chance of making changes to the Medicaid reform language in the House. That is not the case in the Senate. Senators may also examine the advance, refundable tax credits in the House bill. There are some who would like to change that to an appropriated block grant spending program.
Questions have been raised about language in the House bill that might not survive the Byrd rule review process. Some have even suggested that there might be fatal flaws in the House bill that will cause it to lose its designation as a reconciliation bill. While there will certainly be some of the House passed language that will not escape the "Byrd bath," because of the coordination between the House and the Senate, it is unlikely that there are any fatal flaws in the House bill.
During the time the Senate is developing its health care legislation, work will begin on the FY18 budget and appropriations legislation. This can begin while the FY 17 reconciliation bill is still under consideration. Passing a budget for FY18 will be a challenge. With a deficit tax proposal, additional spending for defense, a new infrastructure program, and money for building the wall, it will be quite difficult to balance the FY 18 budget in 10 years. Many House and Senate Republicans will not vote for a budget that does not balance in 10 years. Clearing this hurdle is essential or there will be no FY 18 reconciliation vehicle for tax reform. Add to that the challenge of clearing appropriations bills for FY 18 and increasing the debt limit and you can see that the work has just begun.
The most powerful incentive for Republicans to pass health care legislation is that they have said for seven years that they will repeal and replace Obamacare. That commitment can't be avoided and that is the reason that no matter the difficulties and setbacks, Congressional Republicans and the White House will continue to work on passing a bill to reform health care.
Essential to the success of passing health care reform is to present a vision of what a new health care system can do for the people of America. We have had government control of health care in the U.S. since WWII. First as a mild hand of tax policy pushing corporations and employees to get their health care through tax deductible employer provided policies. Then, recently, with the passage of the ACA, using the muscle of the federal government to control policies, costs, benefits, choices and to mandate decisions for individuals and their doctors.
The vision Republicans have is to create a new system of health care based on the patient-doctor relationship that provides better access, benefits that more directly respond to a family's needs, more choices, more expansive and versatile health savings accounts. This will require more transparency and more freedom for patients, families and their doctors. The ultimate goal is a health care system that offers all Americans the same access, benefits, choices, and health savings programs whether their health care is provided through Medicaid, their employer, Medicare or as an individual.
David Hoppe was Speaker Paul Ryan's Chief of Staff and left his post in the Office of the Speaker in January 2017.
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