As most Americans are riveted by former FBI Director James Comey’s hearing on his firing, Senate Republicans are rushing behind-the-scenes to put together a bill to repeal and replace the Affordable Care Act. Amanda Michelle Gomez, health care reporter at ThinkProgress, reported that while eyes are on the Comey hearing, “Senate Republicans leaders and the health care working group will still be meeting for a working luncheon to continue negotiations.”

Senate Majority Leader Mitch McConnell has implemented Rule 14, allowing the Senate to skip a committee debate and vote and putting the bill on the Senate’s calendar. Gomez reported that McConnell wants a vote by July 4, before Congress leaves for their August recess. Gomez noted that Sen. Claire McCaskill asked Sen. Orrin Hatch if there will be a public hearing, and Hatch said he didn’t know. Andy Slavitt, who ran Medicare, Medicaid and the ACA under President Barack Obama said on Twitter that he’s been informed over seven conversations that McConnell wants the public to only have two days to read the bill, with a day to debate it, and a vote on June 28.

Several reports indicate the GOP is resigned to the goal of getting support from 50 of the 52 Senate Republicans, with the expectation that Vice President Mike Pence would be the tie-breaker. Slavitt said they already have 43 votes.

Republicans are attempting to use “reconciliation,” which Gomez notes is “a 1974 act that expedites the senate’s consideration of bills that pertain to the budget” and which prevents Democrats from filibustering. But the Senate’s process still has more complications than the House’s did:

“Unlike the House, the Senate cannot vote on a bill until the Congressional Budget Office scores it. CBO needs to score the bill to see if it meets budgetary standards of reconciliation. The Senate health bill needs to save $2 billion, which the House bill successfully did. But the Senate bill is also bound by the Byrd Rule, which has its own host of additional surgical rules, like that the bill cannot change Social Security spending or dedicated revenue.”

But what does the Senate bill entail? It’s hard to know, as it’s all being brokered behind closed doors.

Several reporters have indicated disputes within the Senate’s GOP ranks over the House bill allowing insurers to deny coverage to Americans with pre-existing conditions. From Gomez:

“The House bill would also allow states to opt out of some Obamacare regulations by requesting waivers. However, the Senate is looking to preserve one Obamacare protection that prevents insurers from denying care to people with pre-existing conditions. Even so, Senate Republicans are allowing states to opt out of providing essential health benefits to individuals and small group markets. Meaning even though insurers may not be able to deny people with pre-existing conditions, insurance plans may not cover care this community needs.”

Politico also reported that Senate Republicans “appear poised to preserve the Obamacare pre-existing condition protections,” and that McConnell and his team are aiming to submit a “preliminary framework” to the CBO by the end of the week and bring the bill to a floor vote by the end of this month:

“Senate Republicans expect their bill to be more generous than the House-passed measure in almost every way: A longer runway for ending the Medicaid expansion, more money for insurance market stabilization to lower premiums and beefed up tax credits for Americans of lower income, senators said. But no decisions have been made on some key policy questions, including on handling Medicaid.”

Slavitt tweeted that the GOP wants the CBO to review the bill “in pieces.”

Caitlin Owens at Axios has details on McConnell’s proposal for Medicaid, and reported that it’s likely the Senate bill will have waivers allowing states to opt-out from several regulations, but not the ones protecting people with pre-existing conditions — though conservatives are unhappy with that, wanting more of the regulations to be waived.

According to Politico, “there is general GOP consensus around boosting the tax subsidies in the House bill and a general framework of how to reduce premiums. An agreement on Medicaid is unlikely this week, Republicans said, but progress on premiums is more doable.”

The CBO estimated that the House bill would result in 23 million Americans losing health coverage, and a Georgetown University report found rural areas will be hit the hardest by Medicaid cuts. The House bill would cut Medicaid funding by more than $800 billion over 10 years; Medicaid covered 45 percent of children and 16 percent of adults in small towns and rural areas in 2015, according to the Georgetown report. A Kaiser Family Foundation brief estimates that 27.4 million non-elderly adults who have pre-existing conditions might be affected.

The major differences between the Senate and House bills so far seem to be a longer “slope” on ending Medicaid expansion, adjustments to the pre-existing conditions coverage, and more money for tax credits. Like the House bill, the Senate bill seems likely to have Medicaid caps, an end on expansion, and increased premiums. The ultimate goal is to save money to put toward tax cuts.

Further Reading:

“To Be Sick Without Obamacare” (Olga Khazan, July 2017) 

“A complete list of all the reasons Senate Republicans can’t repeal Obamacare yet” (Dylan Scott, May 2017)