The Senate is finally putting its healthcare ideas on paper, as aides are drafting legislative text this week on healthcare reform. But the text is mainly a reference point for continued negotiations and not meant to be a final version, several senators say. Major rifts are festering among Senate Republicans on Medicaid spending and how to lower premiums. Other sticking points are what to do about Obamacare’s individual mandate and the law’s insurer mandates. Other problems include how to ensure that people with pre-existing conditions have affordable healthcare. An estimate from the nonpartisan Congressional Budget Office found that the American Health Care Act, which passed the House earlier this month, would raise premiums for sick people in a state that got a waiver from certain Obamacare insurer mandates.

Time, unlike that Rolling Stones song, is definitely NOT on the GOP’s side. Sen. John Cornyn of Texas told the Washington Examiner last week that his best guess is that the Senate could hold a vote by the August recess, which means lawmakers have only seven weeks in session to write text and vote. The Senate has several pressing matters before it, including making a deal to raise the debt limit. But the debt limit, weirdly enough, isn’t the only deadline facing the Senate. Republicans plan to use the arcane pathway called reconciliation, which lets bills be approved in the Senate with only 51 votes instead of the 60 needed to stop a filibuster. But reconciliation has several requirements. For starters, under the budget resolution to fund the government, Congress has until Sept. 30 to use the tool to repeal Obamacare. After that, Congress would have to pass another budget resolution, further complicating the time frame.

He wants what now? President Trump returned from his foreign trip last weekend and took up his usual habit of tweeting … a bunch. In the midst of Trump tweets on the Russia probe and bashing the media nestled an interesting nugget for health policy folks: “I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead — the Republicans will do much better!” the president tweeted Sunday. Trump didn’t elaborate on where exactly he wants to add more dollars. The AHCA would cut $119 billion from the deficit over the next few years, according to the Congressional Budget Office estimate released last week. Republicans can’t spend more than Obamacare. The two Senate panels tasked with Obamacare repeal have to cut the deficit by $1 billion each over the next decade. If the AHCA adds anything to the deficit, Republicans can’t use reconciliation (see above). However, there are some rumblings that more money needs to be added to high-risk pools, after the CBO said the AHCA’s high-risk pool funding wasn’t nearly enough. Rep. Mark Meadows, R-N.C., the head of the Freedom Caucus, even suggested more funding after the CBO score was released. Trump then tweeted on Tuesday morning that he wants healthcare and taxes to be approved with 51 votes in the Senate, which requires reconciliation — and cutting the deficit. To be sure, Trump has said some things before that didn’t really jibe with what Republicans were planning to do on healthcare and it hasn’t made any impact. He famously said during one interview before taking office that he wants to have “insurance for everybody.” Nobody on Capitol Hill batted an eye at the statement, nor did it change the GOP’s plans on healthcare.

House version already ‘outdated’: CMS Administrator Seema Verma called the American Health Care Act “outdated” when asked about results from the CBO score of the House bill. “What’s more important is what the Senate comes up with and looking at that and the estimates for that,” she said, speaking during a USA Today interview that was live streamed. “Really the House version something that is outdated at this point.” Verma said she was working with the Senate to “make sure some of the president’s core principles are incorporated into the final version.”

Verma also has issues with Medicaid expansion: She raised concerns about the way Obamacare’s Medicaid expansion was designed. “We need a solution for low-income, non-disabled Americans … I question whether Medicaid is the best vehicle,” she said, adding that she thought the program should be designed for those who would be entirely reliant on it, such as people who are disabled and children in poverty. “But this population we hope are individuals who are not going to be staying in poverty,” she said of the Medicaid expansion under Obamacare, adding that she hoped President Trump’s job creation policies would help people purchase private coverage. When asked about work requirements in Medicaid, she said more states could design work requirements for Medicaid but they need the “appropriate safeguards.” “We have made it very clear that we’re open to those types of proposals,” she said. “The idea around community engagement isn’t punitive.”

Medical groups concerned about closed-door talks on Obamacare repeal: Senate Finance Committee Chairman Orrin Hatch, R-Utah, asked a broad array of medical groups and other stakeholders for feedback regarding changes to the healthcare system, but leading medical groups say that appears to be where the collaboration ended. Groups that represent hospitals, doctors and insurers still don’t know what to expect from a new bill, though they say they appreciate providing input. In their letters to members of the Finance Committee, they have raised concerns about various aspects of the House bill, including whether more people would become uninsured, whether plans would receive adequate funding from the federal government, whether people with pre-existing illnesses would continue to be covered, and whether lawmakers would carry out a planned restructuring of Medicaid. “I think the general sense is that the Senate has been much more open to input than the House was,” an industry source told the Washington Examiner. Dick Woodruff, senior vice president of federal advocacy for the American Cancer Action Network, the lobbying arm of the American Cancer Society, which submitted recommendations, said that initially it seemed the Senate would be more inclusive when it came to healthcare talks. “Since then I wouldn’t say that there has been a lot of outreach from other folks in the Senate,” Woodruff said. “The more I read about this and the more time goes by it appears this process is going to be pretty closed.

Grassley preps for town hall: Sen. Chuck Grassley, R-Iowa, is one of the few Republicans holding a town hall over Congress’ week-long recess. He is scheduled to meet with constituents at 2:15 today in Iowa and will hold another town hall Friday. Some other Republicans holding town halls today include Reps. Mark Walker, R-N.C., who voted for the AHCA, and Rep. Leonard Lance, R-N.J., who did not, according to the Town Hall Project. Healthcare is sure to be a big part of any GOP town hall, as activists and constituents are seeking to persuade Republicans to abandon efforts to repeal Obamacare. Fun fact: The raucous town halls during the drafting of Obamacare helped lead Grassley to abandon bipartisan talks on healthcare at the time.

Senate healthcare bill will address the needs of families. That’s a promise from Sen. Bill Cassidy, R-La. He joined the chorus of voices saying the Senate bill would minimize the problems with the House bill recently passed while still living up to Republicans’ promises of replacing Obamacare.

House Democrats plan to batter GOP on healthcare using CBO score: A strategy packet sent to House Democrats is urging members to hold events that allow them to highlight the “terrible consequences” of the Republican legislation. A poll released last week shows the House bill is still unpopular with most Americans. The survey was done before the CBO released their numbers.

Tuesday Group regroups. The resignation of Tom MacArthur, R-N.J., who was co-chairman of the group, has been sparking talks about what’s next for the group of centrists and how they should operate now that at least one major battle on healthcare is behind them. But while the group is looking forward, it also is looking back at how the House healthcare battle ended, and there is something of a split over what lessons should be learned from that fight. MacArthur negotiated a key amendment to the American Health Care Act that would allow states to opt out of key Obamacare insurance regulations, including mandating that insurers cover certain essential health benefits, against the advice of group members. “I don’t know,” MacArthur told the Washington Examiner when asked what’s next for the group. “I made an effort to have the group be more relevant, have more impact as a group. Different members want different things. You can’t lead people where they don’t want to go. I just came to the conclusion that, for me, I don’t want to change who I am. I’m going to keep negotiating with everyone, that includes the Freedom Caucus, and there are members who just don’t want to do that.”

Trump’s budget would hurt veterans benefits: The Democratic Party used its weekly address for Memorial Day weekend to warn of the negative impact the Trump administration’s budget would have on veterans’ healthcare benefits if it came to pass. “We owe our veterans more than a debt of gratitude for their service. We owe our veterans our steadfast commitment to providing them with high-quality healthcare, access to mental healthcare services, a safe place to call home, affordable college and career training programs,” said Sen. Tom Carper, D-Del.
Compiled by Washington Examiner Managing Editor Philip Klein (@philipaklein), Senior Healthcare Writer Kimberly Leonard (@LeonardKL) and Healthcare Reporter Robert King (@rking_19).  Email [email protected] for tips, suggestions, calendar items and anything else.