Basking in the glow of the White House Rose Garden last week, the Trump administration and a large group of House Republicans celebrated passage of the American Health Care Act (AHCA) in the House. AIDS United denounced passage given that it will likely result in the loss of insurance for more than 24 million people including people living with HIV. Despite being forced to ignominiously pull the initial version of the bill in March, Republican leadership in the House and President Trump hailed their slim 217 to 213 legislative victory in a very public fashion. Clearly the White House and House were attempting to send a message to the Senate that repeal and replace of the Affordable Care Act (ACA, or Obamacare) was a foregone conclusion and that AHCA’s passage in the Senate was all but assured. “We’re going to get this passed through the Senate,” President Trump said. “I feel so confident.”

Unfortunately for President Trump and Republican congressional leadership, and fortunately for people living with HIV and everyone else who has benefitted from the provisions of the ACA, that confidence is not grounded in legislative reality. House Republican leadership may have succeeded where they had previously failed by passing the revised version of the AHCA, but, in doing so they wound up creating a toxic and untenable piece of legislation that Senate Republicans have made clear has no chance of passing the Senate as is.

“The House bill is not going to come before us,” said Sen. Susan Collins (R-ME) shortly after the House passed their version of the AHCA. “The Senate is starting from scratch.”

Tennessee Sen. Bob Corker was even more dismissive of the House’s bill, saying shortly before the vote that he “turned the volume off some time ago and have no idea what the House is even passing.” Despite their confidence that the bill would be fully rewritten, AIDS United and other organizations that oppose the House bill planned to weigh in since the Republican efforts to cut funding from Medicaid remain a primary purpose of the bill.

With the House version of the bill essentially dead on arrival, Senate Republicans have a heavy workload ahead of them to write and pass their own version of health care legislation. Additionally, given constraints imposed by reconciliation, there is a closing window of time in which they must pass the bill. Senate Republicans have not issued a formal time table for their version of the AHCA, with multiple Republicans stressing that there will be no “artificial deadlines” imposed on the process. Senate rules dictate that the Senate parliamentarian cannot determine the rules for debate until the Congressional Budget Office (CBO) has scored the legislation. CBO has said that they will score the legislation by next week. Such a delay will likely push floor debate on any Senate health care bill until at least June.

In preparation for the task of rewriting of the AHCA, Senate Majority Leader Mitch McConnell (R-KY) created a “13-man” working group of Senate Republicans that will take on the daunting task of crafting a piece of legislation that satisfies the more moderate members of the Senate GOP while remaining palatable to staunch conservatives like Sen. Ted Cruz (R-TX) and Sen. Mike Lee (R-UT). The use of the phrase 13-man working group above is very intentional, as Sen. McConnell has assembled around him a mostly conservative, all-male team of Republican Senators to constitute the membership of the working group, a move that has understandably caused varying degrees of outrage and consternation from Democrats and even some Republicans.

Aside from McConnell, the Senate health care working group contains the rest of the Senate’s Republican leadership, with Senate majority whip John Cornyn (R-TX), Senate Republican Conference chair John Thune (R-SD), and Senate Republican Policy Committee chair John Barrasso (R-WY) all included. Also joining them in the working group are Senate health committee chair Lamar Alexander (R-TN), Senate budget committee chair Michael Enzi (R-WY), and Senate finance committee chair Orin Hatch (R-UT) along with a handful of Senators from states that implemented Medicaid expansion— Sens. Tom Cotton (R-AR), Cory Gardner (R-CO), Rob Portman (R-OH), and Patrick Toomey (R-PA)—along with the aforementioned Sens. Cruz and Lee.

Conspicuous in their absence from the working group were Maine Senator Susan Collins and Alaska Senator Lisa Murkowski, two of the moderate swing votes that McConnell and Senate Republican leadership can ill afford to lose if they want their version of the AHCA to pass. With only 52 Republicans in the Senate, all it takes to derail any legislation is a trio of GOP senators who are willing to buck the party line. Given that both Murkowski and Collins have been vocal opponents of using the ACA repeal and replace process to defund Planned Parenthood, it is a hefty gamble by Senate Republican leadership to leave them out of the working group and pursue a bill that will more than likely retain the House AHCA’s language excising Planned Parenthood funding.

Should Sens. Collins and Murkowski wind up opposing the Senate version of the AHCA, all they would need to do is recruit someone like Sen. Bill Cassidy (R-LA), with whom Collins co-sponsored the moderate Patient Freedom Act of 2017 back in January that would have given states the option to essentially keep the ACA if they wanted to, or Sen. Dean Heller (R-NV), who faces re-election in 2018 in a state carried by Hillary Clinton, and the Senate version of the AHCA would fail. Add to that the sizable number of GOP Senators like Sens. Shelley Moore Capito (R-WV) and Jeff Flake (R-AZ) who come from states who have benefitted mightily from a Medicaid expansion that was slashed in the House version of the AHCA, and Senate Republicans have left very little room for error if they wish to get any legislation passed.

Going forward, it will be the responsibility of us here at AIDS United and of HIV advocates across the country to let Senate Republicans and Democrats know exactly what we find acceptable in any piece of legislation that they produce. Most importantly, AIDS United will continue to oppose provisions that will repeal or roll back Medicaid expansion or create per capita caps on Medicaid which will ultimately force states to cut eligibility and benefits. It is especially important to impart the message to Senate Republicans that it is unacceptable to support the dangerous and deadly provisions included in the House’s version of the AHCA.