Senate health care plan: What happens now?

Senate Majority Leader Mitch McConnell on Tuesday delayed a vote on the Senate health care bill until after the July 4 recess, giving his caucus more time to negotiate changes to the proposal but leaving the GOP campaign promise to repeal and replace Obamacare in limbo.

Here’s what happens next:

Where Republicans stand:

GOP senators are back behind closed doors, trying to hammer out some kind of path forward.

What to watch Wednesday:

Nothing public of note – keep gauging wary senators and trying to tap into the potential compromise agreements floating back and forth behind closed doors. The goal is to have a deal on a new draft by Friday, get it scored by the non-partisan Congressional Budget Office next week and vote on it when they return from recess.

Getting a new bill done by Friday is an ambitious goal, that could very well slide, a senior GOP aide acknowledged to CNN.

The big question:

What’s going to change in three days – or 13 days – to make this happen? Senators are going to have to move away from firmly, publicly held positions if McConnell is ever going to get the 50 votes he needs to pass this legislation. Who is going to do it first?

President Donald Trump’s role, as viewed from the Hill: “He has his role. We have ours. There probably won’t be much intersection,” one senior GOP aide said after his boss came back from a White House meeting Tuesday. The point being: details and negotiating will be handled in house. The President “will do social media and make big promises on TV.”

Tuesday was the second straight meeting with GOP senators (the first one was with a smaller group a few weeks ago) where it was clear, at least to senators in attendance, the President wasn’t read in on the in-the-weeds details and concerns of individual members, according to two people with direct knowledge of the meeting.

Those people described it as a good meeting – one in which the President mostly listened, talked about the promises made to constituents and the need to add some money to the bill. When lawmakers and aides tick through the White House operation, it’s clear Vice President Mike Pence is very much in the thick of it. The President’s legislative team has been in the room every step of the way. Administrator of the Centers for Medicare and Medicaid Services Seema Verma is constantly on the phone with GOP senators.

But the President? “He’s not the details guy,” the aide said. “And senators need details.”

The Heller ads:

You can’t overstate how infuriated GOP senators are about ads a pro-Trump super PAC ran against fellow Republican Sen. Dean Heller of Nevada, criticizing him for opposing the bill. Republicans raised it behind closed doors to Pence Tuesday, and again to Trump. McConnell (and his outside allies) raised it to several people on the President’s political orbit. The bruises from this stunt aren’t going to heal any time soon.

Profiles in courage:

Three GOP senators came out firmly opposed to draft bill after McConnell delayed the vote and promised changes. That makes nine total. A few others, most notably Sen. Ben Sasse of Nebraska, broke their general silence to say they had problems with it. What does that mean? Two things:

1. Not unlike the four conservatives who came out immediately after the draft was released, this was in part a negotiating tactic. If you come out publicly against something, you’re positioning yourself to try and secure future changes.

2. It is, say, politically advantageous to oppose something with a low double-digit approval rating that you know leadership isn’t going to make you vote on (for now)

The newly declared “no” votes underscore something CNN reporters been hearing for a few days: the opposition was far deeper than was publicly known.

So what’s it all mean:

The reality is the dynamics haven’t changed. McConnell knows quite well what each of his members wants to get to yes. Similarly, he likely knows what they *need* to get to yes. He has money to give moderates in the near term. He can pitch regulatory changes to the conservatives. That wasn’t enough this week. Now it’s a question of how to get enough of them into a single bill, while not completely alienating the other side of the ideological spectrum, and somehow manage to get to 50 votes.

What they want:

Sens. Rob Portman of Ohio/Shelley Moore Capito of West Virginia/Susan Collins of Maine: Opioid funding

Heller/Capito/Portman: Return Medicaid growth rate as pegged to medical inflation

More from Heller: Slower Medicaid expansion phase out; don’t allow states to strip out essential health benefits; whatever else Republican Gov. Brian Sandoval of Nevada says he wants or needs

Sens. Ted Cruz of Texas/Mike Lee of Utah/Rand Paul of Kentucky/Ron Johnson of Wisconsin: Allow competing insurance plans completely exempt from Obamacare regulations to be sold/more HSA flexibility

Collins/Lisa Murkowski of Alaska/Jerry Moran of Kansas: Rural hospital funding

Collins/Murkowski: Strip out plans to defund Planned Parenthood

Paul: Significant changes to: the subsidy structure, regulations, Health Spending Account flexibility, Medicaid expansion phaseout, etc.

A final (really) important point:

At the center of the Republican inability to reach a compromise here are significant, intra-party ideological differences on how to approach health care.

The simple fact is a large chunk of the Senate GOP conference likes the central pieces of Obamacare, and whether for political reasons or policy, they don’t want them to go. That’s an anathema to the other side of the conference and to all the conservative outside groups.

In other words: these aren’t minor policy quibbles and stubborn fights over parochial issues. This is about belief systems (or constituent belief systems, reflected by their senator) on what the government’s role should be in health care. And a real question of whether that gap can ever be bridged.