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The conservative Republican Study Committee is preparing to send a letter of demands to Senate Majority Leader Mitch McConnell this week as he finalizes the upper chamber's version of the bill to replace Obamacare.

The RSC letter, obtained by Independent Journal Review, begins, “We write to express our serious concerns regarding recent reports suggesting that the Senate’s efforts to produce a reconciliation bill repealing the Affordable Care Act are headed in a direction that may jeopardize final passage in the House of Representatives.”

The letter goes on to describe the House's health care process, noting it featured “vigorous and robust debate” between members. That process allowed House members to add their desired changes to the bill, like income caps for refundable tax credits, work requirements for Medicaid, and the ability for states to scrap Obamacare regulations.

By contrast, the process in the Senate has been secretive.

The legislation has been drafted swiftly and without hearings or public debate on its various provisions as the Senate leadership negotiates with the most moderate and conservative members to get the bill to the 50-vote threshold.

Warning Signs

But most Republican lawmakers haven't seen McConnell's health care bill text, even though the legislation is almost complete.

The secrecy hasn't stopped conservatives from recognizing warning signs that their priorities won't be reflected in the bill.

In the letter, Rep. Mark Walker (R-N.C.), who chairs the RSC, lays out four components of the House-passed health care bill that are “particularly crucial” to maintaining support from GOP lawmakers in the House. It says McConnell's bill should include AHCA's provisions to:

  1. “Immediately prohibit new states from receiving an enhanced federal share for expanding Medicaid,” and impose a phaseout of the ACA's Medicaid expansion by 2020.
  2. “Allow states to waive certain onerous requirements imposed by the ACA,” through the MacArthur amendment which allowed states to scrap Essential Health Benefits and community ratings mandates.
  3. Repeal taxes introduced by Obamacare “in the most expeditious manner possible.”
  4. Strip federal funding from Planned Parenthood for a year, and include Hyde amendment language to ensure the plan's refundable tax credits can't be used to pay for abortions.

All four of those demands face challenges in the Senate.

McConnell is walking a thin tightrope to keep votes, and in doing so, he has opted to draft a more moderate version of the health care bill.

Trouble Spots

On the first point, Republican senators from states that used the ACA's Medicaid expansion are reluctant to cut funding to the program, because many of their constituents have gained insurance through it. The Senate bill is still expected to include a rollback of the Medicaid expansion, but on a slower timeline than the House bill.

Second, the RSC's request that the MacArthur amendment allowing states to waive Obamacare regulations be included also isn't likely to make it into McConnell's bill. Those mandate waivers aren't popular among most Republican senators, and McConnell has indicated he doesn't support them, either.

The Congressional Budget Office found that getting rid of community ratings — a rule preventing insurers from charging individuals with pre-existing conditions higher prices for coverage — would cause premiums for sick people to skyrocket and would lead some of them to be priced out of the market.

The CBO report also concluded that the House health care bill's high-risk pools intended to cover individuals with pre-existing conditions wouldn't have enough funding to cover them.

Senate Republicans are expected to take a different route.

Third, the RSC's call for Obamacare taxes to be repealed as quickly as possible is still under consideration in the Senate, where GOP leaders are considering leaving some taxes intact for a little longer in order to pay for a slower Medicaid phaseout.

Finally, the RSC's demand for Planned Parenthood funding to be cut along with the Hyde language preventing federal funding for abortion is a tough sell with at least two Republican senators, Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska).

Not Much Room to Maneuver

Republicans can only lose two votes to still pass the bill in the Senate with a tie-breaking vote from Vice President Mike Pence.

The strict rules of reconciliation, the budgetary procedure Republicans are using to pass a health care bill, might prevent the Hyde language, which stops federal dollars from paying for abortions, from being included in the plan's refundable tax credits.

McConnell and Senate leaders will work on the contentious points of their bill this week, and they hope to get the legislative text to the CBO fast enough to hold a vote before the July 4th recess.

But the letter is yet another indication that even if the Senate is able to vote on that timeline and pass its bill, officially replacing Obamacare will still be an uphill climb for Republicans.

“We eagerly await the day when we can fulfill our promise to the American people and send legislation to the president’s desk repealing and replacing the Affordable Care Act,” the letter concludes. “As the Senate continues its deliberative process, we urge you to carefully evaluate the American Health Care Act and consider the important role these specific policies played in building consensus in the House.”