To great fanfare by both the leadership of the Republican caucus in the House of Representatives (the House) and President Trump, on May 4, 2017, the American Health Care Act (AHCA), the proposed successor/replacement to the Affordable Care Act (ACA), passed the House by a narrow vote of 217-213. Unsurprisingly, no member of the Democratic Party in the House voted for the bill, but what should have been an easy vote was a bit of a nail-biter, as 20 members of the Republican caucus voted against the legislation. While a victory, it is a slim margin. The question that has been bandied about over the last several days is simply, what happens next?

Much as is depicted in ‘Schoolhouse Rock’, the bill travels to the other end of the Capitol building, where the Senate begins its process. The Senate has chosen the reconciliation process, which only requires 51 votes, or a simple majority, for approval. While this threshold appears to be an easier one to meet, it is deceptive. In an interview with ABC News, Senator Roy Blount, R- Missouri, stated, “At the end of the day, I think it’ll be a Senate bill and then those two bills at some point will have to come together and we’ll get started on that Senate bill immediately.” Reconciliation means combining portions of the two bills, the AHCA and the as-of-yet undrafted Senate bill.

To complicate matters even further, prior to the Senate commencing its review of AHCA, the Senate Budget Committee must analyze it to see which portions of the bill are in compliance with the rules on reconciliation. Reconciliation requires that all aspects of the bill be tied to the budget, the so-called Byrd rule. Any aspects of AHCA which are not compliant cannot be included in the Senate bill, and would be subject to revision or exclusion to ensure compliance. It should be noted that for the Budget Committee to conduct its analysis, the Congressional Budget Office (CBO) must first score the bill. The House did not wait for a CBO score on this bill prior to bringing the legislation to the floor for a vote.

This is, rather obviously, a time-consuming process, and we should not expect a speedy production of a final bill. Moreover, once the Senate begins drafting its legislation, there are disparate voices expressing concerns. First, it is not expected that any Senate Democrats will vote in favor of any repeal/replace legislation to the ACA. Immediately that is 48 votes against the bill (46 Democrats and 2 Independents who caucus with the Democrats). Additionally, Republican Senators Cory Gardner (Colorado), Lisa Murkowski (Alaska), Rob Portman (Ohio), and Shelly Moore Capito (West Virginia) all hail from states that expanded Medicaid under the ACA, and are concerned about a lack of protections for their states’ beneficiaries. Also, Senator Susan Collins (R-Maine) has expressed concerns regarding attempts to include defunding of Planned Parenthood as part of the legislation. Lastly, conservative Republican Senators Rand Paul (Kentucky), Mike Lee (Utah), and Ted Cruz (Texas) have all tweeted they would only support a bill that is a full repeal of the ACA.

We should expect a reconciled Senate bill in several weeks, not days. We will continue to monitor the process and publish updates as they develop.