The Republican bill to retool the Affordable Care Act may stall in the Senate, where legislators have different concerns than their House peers.
It took Republicans almost two months to cajole their own representatives into voting for the party's plan to gut Obamacare, but getting the bill passed in the Senate could be far more challenging.
Senators are going to look almost exclusively at the Medicaid provisions, one analyst says, and they already don't like what they see.
The bill passed the House last Thursday by a vote of 217 to 213, with just one more "yes" vote than needed. All 193 voting Democrats and 20 Republicans opposed the bill.
The American Health Care Act (AHCA) would reform the Affordable Care Act by removing the Obamacare rule requiring most Americans to have health insurance coverage and allowing health plans to impose a 30% premium surcharge for consumers with gaps in coverage.
The AHCA also would end the requirement that plans offer a minimum set of benefits and would allow insurers to charge more for pre-existing conditions if the state has an available alternative such as a high-risk pool.
Proponents of the Republican bill shouldn't celebrate the House passage too much, says Julius W. Hobson Jr., an attorney and healthcare analyst with the Polsinelli law firm in Washington, DC.
"The bill as passed by the House has virtually no chance of passage in the Senate," Hobson says.
"The issue in the House was essential benefits, but the big concern in the Senate is and always has been Medicaid. Leading senators have already expressed concern about the cuts in Medicaid, and given the narrowness of the Republican majority, this is not going anywhere in the Senate."
Under the Republican bill, Medicaid would be cut a total $880 billion over 10 years. Rather than an open-ended revenue stream from Washington, states would receive a set amount of federal funds for each beneficiary. If they agree to accept the funds in a lump sum as a block grant, the federal government would impose fewer requirements.
'Start from Scratch'
"Senate leaders have already said they're not going to take up the House bill and are going to start from scratch if they pass anything at all. That tells you right there that the House bill is not going to become law," Hobson says. "The question is, if the Senate is able to pass a bill and get it through reconciliation with the House, can that bill be passed in the house?"
At that point, the Freedom Caucus could block the bill just as it blocked an earlier version of the Republican bill, Hobson notes. The powerful caucus of conservative and libertarian House members took a hard line on the earlier bill because it did not change the ACA enough, and Hobson says it is likely to see a reconciled bill from the Senate as a watered down version of the bill just passed.
"Whatever comes out of the Senate will be more liberal than what the House just voted for, and that one just got by with the bare minimum of support needed," Hobson says.
"For legislation that affects one-sixth of the nation's economy, you can't do that on one side of the aisle. You almost always end up with something that one side, or both sides, think will still need to be fixed at some point."
Gregory A. Freeman is a contributing writer for HealthLeaders.