Health care state of play: This is the week senators vote (or not)

Pence: GOP senators must step up to the plate
Pence: GOP senators must step up to the plate

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Story highlights

  • The Senate Parliamentarian's ruling Friday threw a wrench into plans
  • Republicans are expecting a vote this week but the numbers don't look good
  • Even if a vote fails this week, it doesn't mean health care discussions are over

(CNN)For anyone tracking Republicans' plans to repeal and replace Obamacare, this probably sounds familiar: it is possible GOP senators come back to Washington to vote on a health care proposal this week.

At least that's the plan.
    But there's a catch: Republicans are returning uncertain on what their leadership is asking for them to vote on and there is no indication that the votes are even close to being there.

    What to watch on Monday:

    Things are going to be slow on Capitol Hill, at least until Monday evening when GOP leadership meets behind closed doors. That is where we will get the first indication of whether any plans have shifted or changed. We'll also get the first reaction to the Byrd Rule guidance the Senate Parliamentarian dropped like a grenade into the debate on Friday night (see below for details on this).
    But Capitol Hill won't be the place to watch at first. West Virginia wins that battle Monday, where President Donald Trump will be appearing. By his side? Shelley Moore Capito, a Republican senator who remains a clear holdout on backing GOP plans for health care. This brings the full weight and power of the presidency to the forefront. Capito hasn't buckled a bit in past weeks, so any shift here would be major. And, frankly, so would a non-shift.
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    Where are the plans right now

    Have the vote. Leadership is still short the 50 votes it needs to advance its legislation under the rules of the Senate procedure known as reconciliation.
    Sen. Susan Collins of Maine is a concrete embedded "No." If leadership brings up the "repeal and replace" bill they have been working on for months.
    Sen. Rand Paul of Kentucky is also expected to stop the bill from advancing.
    Sen. John McCain hasn't given any indication he's coming back as he continues to fight cancer.
    Leadership can only afford to lose one member of their conference, and there's at minimum six, and even up to 10 who are uncomfortable with moving forward at this point.
    Still, the prevailing consensus through the weekend was that a vote needs to be held, even if it's going to fail.
    "It's time to put everyone on record," one senior GOP aide told CNN on Sunday. "At this point, nothing's going to change until we do."
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    What happens if the vote fails?

    It ain't over. More and more, by the end of last week, it became clear that the effort to strike some kind of deal on "replace" was kicking back into gear.
    Republicans huddled in the office of Sen. John Barrasso of Wyoming for hours and members and more conversations with the administration continued into the weekend. With that in mind, there are more than a few members and staffers who think the failed procedural vote may serve as a spark of sorts to those efforts.
    "The reality of failure, and the blowback senators are likely to get from the base, may serve to help us in the end," a Republican aide working on the process told CNN.
    Trump pointed in that direction Sunday night via Twitter: "If Republicans don't Repeal and Replace the disastrous ObamaCare, the repercussions will be far greater than any of them understand!"

    But keep in mind: The ideological dynamic hasn't changed.

    Conservatives want more of the Obamacare regulatory infrastructure cut back. More centrist senators have very specific (and in many cases, very large -- at least in terms of funding) requests from the opposite side of the spectrum. Nothing has shifted on that front.
    The Trump administration is driving a very clear effort to try and bridge that gap -- and relying heavily on the administrative (and creative) powers of Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, to try and get that done. It hasn't worked so far. So what's different this time?
    As one senior GOP aide put it at the end of last week: "Well, nothing yet."

    Let's get procedural

    There were lots of complaints last week from Republican senators about not knowing what they're actually going to be voting on come Tuesday. And yes, that's true. But to some degree it's always been the case. Reconciliation allows for a "vote-a-rama," in other words any germane amendment, from any member of the Senate that is within the budget rules, can be offered. So uncertainty was always going to be an element.
    What's different now is there's no agreed upon "repeal/replace" substitute amendment. That was what leadership wanted locked in before this process started on the floor and what they have been working toward for months. Ideally, at the end of the vote-a-rama, the agreed upon repeal/replace amendment would be put up for a vote, stripping everything else and replacing it entirely with compromise language that could get 50 votes. As of this moment, they are still woefully short of that goal.
    Previous CNN reporting raises all the very real problems with not having an agreement in advance here.
    So, barring some last minute "replace" agreement, here's how the vote would work:
    Procedural vote, likely Tuesday, on the motion to proceed to the House-passed health care bill.
    If the procedural vote passes:
    • Move onto the debate and amendments to the House bill.
    • Any senator can offer any germane, within the rules amendment (the 2015 repeal-only bill among them)
    • Senate leaders continue negotiating behind the scenes to lock in a "replace" amendment, with the full weight and pressure of everything officially in motion on the senators holding out.
    • The amendment process will go for hours upon hours, into the next morning, with a vote on a final amendment, and then final passage likely at 4 a.m. ET or 5 a.m. ET (Don't undersell exhaustion as a tool in favor of leadership this process).
    If the procedural fails
    • Back to the drawing board, senators go back behind closed doors and keep negotiating (a procedural vote can be brought up again if an agreement is reached), with the goal of reaching agreement on a replace plan that can get 50 votes, then starting the voting process again.
    • OR Senators throw up their hands, urge a shift to tax reform (and a shift back to an on-schedule, five-week August recess.)

    What the Friday's Byrd droppings mean

    Problems. And not just for pro-life conservatives.
    There are 10 provisions in the bill, many of which are absolutely central to a functioning marketplace, that the Parliamentarian said would likely run afoul of reconciliation rules, and as such, require 60 votes to remain in the bill (Breaking: Republicans would not be able to get 60 votes for any of those provisions). There are a handful of others still being looked at by the Parliamentarian that may also not pass muster. And the all-important "Cruz amendment," from Texas Sen. Ted Cruz, which Democrats (and quietly some Republicans) are confident won't get the nod, hasn't even gone through the process yet.
    Another major problem for Republicans is that the Parliamentarian ruled that a provision in the House bill dubbed the "Buffalo buyout" didn't pass muster because it so clearly was designed for one state and one state only.
    That's not good because one of the tools leadership has had is to buy individual members off. In fact, the revised "Better Care Reconciliation Act" bill included a provision specifically designed to toss more money to Alaska and Alaska only. If one of the tools you use to get on-the-fence members is no longer as viable, that's trouble.
    Important note here: These aren't "rulings" by the Parliamentarian and they don't "strip" anything from the bill. This is guidance, provided to staff and members, about what will and won't stay within the rules at the moment. Republicans, with some very smart, very clever staffers, can now redraft and revise these provisions to try and bring them in line, which they most certainly will.
    But the Planned Parenthood and anti-abortion tax credit provisions haven't changed in draft after draft. And the ability to revise them in a way that passes muster with the Parliamentarian, is a very open, and extraordinarily crucial question.
    Confused as to what the the Byrd Rule mumbo-jumbo is all about? Read this.

    What is the White House doing?

    You might have noticed Trump's tweet Sunday afternoon targeting GOP members for not being with him. It was vague, but seemed intended to pressure some to rethink their position on health care.
    "It's very sad that Republicans, even some that were carried over the line on my back, do very little to protect their President," Trump tweeted Sunday.
    Over the weekend, Pence also went out to campaign for health care, stopping Saturday in Ohio where he said it was time for Republicans to "step up to the plate."
    But how much of an affect the White House can actually have on this process remains to be seen. It's key to remember that senators -- so far -- don't appear to have much trust in Trump to be with them if this bill isn't popular down the line. Remember what Sen. Lindsey Graham, a South Carolina Republican, said last month.
    "Here's what I would tell any senator: If you're counting on the President to have your back, you need to watch it," Graham said.