What's likely to happen to the health bill in the Senate Presented by

Don't get attached to Republicans' health bill: It's about to undergo reconstructive surgery.

AFTER ALL THAT, THE SENATE IS STARTING OVER — After all the effort expended by the House to pass the American Health Care Act, the upper chamber immediately signaled that it's starting fresh.

“We’re writing a Senate bill and not passing the House bill,” said Sen. Lamar Alexander (R-Tenn), minutes after the American Health Care Act squeaked past the House in a 217-213 vote. “We’ll take whatever good ideas we find there that meet our goals.”

Put another way, the "House passage gives the Senate the opportunity to write a bill," Sen. Chuck Grassley (R-Iowa) said in a statement.

Senate Republicans signaled they'll take a more deliberate approach to reform than House Republicans, who repeatedly set aggressive deadlines before holding votes. "Any bill that has been posted less than 24 hours, going to be debated three or four hours, not scored?" mused Sen. Lindsey Graham (R-S.C.). "Needs to be viewed with suspicion." More.

On timing: We're still weeks away. The Senate parliamentarian can't review the legislation and set up the terms of debate until the Congressional Budget Office analysis is complete, which could still take several weeks. That pushes the Senate's debate until at least June.

Senators also have been occupied with their chamber's own priorities and not consumed with the frenetic health care discussion. “I turned the volume off some time ago and have no idea what the House is even passing,” Sen. Bob Corker (R-Tenn.) said shortly before the vote on AHCA was scheduled.

… The top House Republican took a subtle swipe at his counterparts at yesterday's celebratory conference in the White House's Rose Garden.

"I know that our friends over in the Senate are eager to get to work," House Speaker Paul Ryan said. "They are," Ryan insisted with a smile, as the crowd and assembled House Republicans laughed.

On issues: Expect a push to relax AHCA's coverage cuts. Senate Republicans are considering staunching the coverage losses projected under the House by altering the Medicaid repeal, making tax credits more generous and strengthening protections for people with pre-existing conditions.

Other wrinkles to watch in the Senate

— Senators are less pliable under White House pressure than House members. Just eight Republican senators are up for reelection next year, with only two — Sens. Jeff Flake (R-Ariz.) and Dean Heller (R-Nev.) — thought to be in vulnerable seats. Both are in Medicaid expansion states.

The remaining GOP members who aren't up for reelection until 2020 or 2022 and oppose the plan may decide they can wait out Trump if he remains a historically unpopular president.

— CBO score is still looming. It may not have stopped House Republicans, but the Congressional Budget Office is going to issue its revised analysis of the American Health Care Act in the days ahead. And based on preliminary estimates from external groups and former CBO analysts, it's going to be another grim projection, perhaps worse than before. That will likely renew criticism of Republicans' overall effort, right before the Senate takes up health reform.

— Byrd rule could be disqualifying. It's possible that the Senate parliamentarian will rule that AHCA doesn't qualify for budget reconciliation because it includes provisions that don't change spending or revenue levels. (Senate Democrats have loudly argued that the bill will be disqualified).

— The fate of Obamacare subsidies is up to Trump. The future of the much-debated funding rests with the president, Sen. Alexnder said. "Unless we can find a way to include that as part of the Senate bill in reconciliation — and I’m not sure that it can be — that’s up to the president to decide," he told POLITICO's Jennifer Haberkorn.

— Red state Democrats line up against the bill. Senate Republicans can only lose two votes but can't count on any minority defections: All 10 Democrats up for reelection next year in states won by Trump blasted the Republican effort, POLITICO's Elana Schor notes.

Democrats believe that the GOP repeal bid is backfiring — making Obamacare more popular — but their tactic is also a response to a squeeze play by Senate Republicans, who are pushing through their repeal plan with no minority input. More.

IT'S FRIDAY PULSE — Where your author is still sifting through the hundreds of post-AHCA reactions in his inbox, but one grabbed him with its vehemence.

“The worst health care bill in American history now goes to the Senate," said Kenneth E. Raske of the Greater New York Hospital Association. ("The hospital community will continue to aggressively oppose it for the sake of our patients and employees," Raske added.)

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With help from Adam Cancryn (@AdamCancryn) and Jen Haberkorn (@JenHab).

GUIDE TO FEDERAL BUDGET & APPROPRIATIONS PROCESS: The federal budget process is complicated; brush up on your knowledge so you’re ready to act as the budget winds its way through Congress. Download your guide.

WHAT THE HOUSE BILL WOULD DO — To paraphrase, some House Republicans said they had to pass the bill so Americans could find out what was in it. Perhaps one reason for that is because a few members confessed on Thursday they didn't read the full bill.

"I could probably tell you that I read every word, and I wouldn't be telling you the truth, nor would any other member," Rep. Chris Collins (R-N.Y.) told CNN's Wolf Blitzer. See 34-second video.

Among the last-minute changes and overlooked cuts:

— Community rating waivers could destabilize the employer insurance market. A possible change made possible by the MacArthur-Meadows amendment — first highlighted by Brookings Institution economist Matthew Fiedler — would allow states to receive waivers to exempt Obamacare plans from offering essential health benefits. But the change also would allow employers to similarly drop services like maternity and mental health care from their plans too, Fiedler noted.

If "even one state elected to completely eliminate its essential health benefit standards, the requirement to provide these protections would effectively disappear entirely for large employer plans nationwide," Fiedler warned. More.

— The $1 billion prevention fund would be repealed. The fund represents roughly 12 percent of the Centers for Disease Control and Prevention’s budget and covers some immunization programs, grants for preventive health services and programs to protect against outbreaks like the Zika virus, Pro's Brianna Ehley reports.

Public health experts decried the cut. “[A] big blow to public health in this country,” said Scott Becker, executive director of the Association of Public Health Laboratories. More for Pros.

A message from PhRMA: Today, there are several promising vaccine candidates in stage three clinical trials. These trials have tens of thousands of participants, from every walk of life. From development to robust clinical trials, and throughout manufacturing, these vaccine candidates follow the same rigorous process of other vaccines that have saved millions of lives. More.

LEADERSHIP JUBILENT — Republican leaders crowed about the outcome, saying it was the most significant achievement of Trump's term and a major blow toward rolling back Obamacare, despite only being a fraction of the way toward full passage of the bill through Congress.

… But Democrats also celebrated the outcome in a fashion, with members chanting "hey hey goodbye" to their GOP counterparts after the vote was completed, taunting them with the threat of losing their seats. House Minority Leader Nancy Pelosi later said the chant was "spontaneous," but repeatedly reiterated that voters would punish Republicans next year.

Some Democrats even told PULSE that Republicans would get punished by their base voters for not going far enough to repeal Obamacare, by leaving big pieces of the law still intact. "It's another broken promise" by Trump, one Democratic leadership aide told PULSE.

In the zero-sum world of congressional seats, of course, both parties can't be right.

Who took a victory lap at the White House — Eleven different speakers took the podium to celebrate.

— Trump

— House Speaker Paul Ryan

— Majority Leader Kevin McCarthy

— Majority Whip Steve Scalise

— E&C Chairman Greg Walden

— Budget Chairwoman Diane Black

— W&M Chairman Kevin Brady

— Freedom Caucus leader Mark Meadows

— Tuesday Group co-chair Tom MacArthur

— CMS administrator Seema Verma

— HHS Secretary Tom Price

“Patients and families and doctors ought to be making medical decisions, not Washington, D.C.,” Price said in his own victory speech. “I can’t wait for the day, Mr. President, when we’re able to come back to the White House." See video.

… The victory celebration — and Price's comments — didn't sit well with liberal advocates.

"When the administration says it wants to move decisions away from Washington, it really means they want to remove consumer protections and allow insurance companies to decide what to cover," said Andy Slavitt, the former head of CMS in the Obama administration. "Rhetoric around empowering physicians and patients simply isn't credible."

More pessimism among the ranks. Dissenting Republicans worried that they, and their constituents, would suffer for the bill's passage.

The AHCA "will increase health insurance costs particularly for low-to-moderate income Americans, increase the number of uninsured by as much as 24 million people, and undermine important protections for those living with pre-existing conditions," said Rep. Charlie Dent (R-Pa.), the co-chair of the center-right Tuesday Group. He called the bill "haphazardly constructed and hastily considered," adding "we must and can do better."

"We're doing some of the very things that we criticized the Democrats for doing with Obamacare," GOP Rep. Pat Meehan said in an interview on Thursday morning. Both Dent and Meehan voted against the bill. See the full list of Republicans who dissented.

… Democrats also mourned the potential loss of the Affordable Care Act, the signature legislation of former President Barack Obama's two terms in office. "They take away coverage from 24 million … and they cheer," Rep. Elijah Cummings told PULSE. "There's some kind of empathy deficit."

The House Republicans who could lose their jobs over Obamacare repeal. Reps. Darrell Issa, Carlos Curbelo and Peter Roskam are among the lawmakers who said yes to the AHCA but come from districts that Hillary Clinton won. Pro's Kevin Robillard runs down the list of vulnerable members: More for Pros.

Why they're so vulnerable: “The negatives in this bill are more than just one talking point or one television ad,” said Jesse Ferguson, a Democratic strategist who ran the Democratic Congressional Campaign Committee’s independent expenditure arm in 2014. “It is an entire campaign’s worth of negatives that these Republicans are taking ownership of as they walk the plank.”

… "217 Republicans voted for AHCA," WaPo's Dave Weigel reports. "As of now, only seven of them have town halls scheduled for the recess."

HOW THE VOTE PLAYED IN THE PRIVATE SECTOR — Not well, with many providers already fretting about their future. Executives at one mid-sized hospital projected that if the AHCA took effect as written, the hospital's margins could plunge to negative 10 percent or worse.

Patients are especially alarmed. "Since November, I've had personally at least 15 clients ask to get to treatment, ask for more therapy, ask for more psychiatric care/visits because they are afraid that their benefits could be repealed at any time," said Mike Ferguson, who runs an addiction and mental health consulting group. "I spent the majority of my day today talking with insurance-dependent clients who are terrified that they'll go back to their old ways if they can't afford medication, let alone therapy or treatment."

"We are literally trying to create multiple scenarios trying to plan for every possible event," said a staffer with one mid-size insurer. "We can work with bad policy, fine, but give us certainty is the general mood."

VIRAL VIDEO: Trump tells Australian prime minister that 'You have better health care than we do.' Less than five hours after the Republican bill to dismantle Obamacare passed the House, the U.S. president complimented Australia's Malcolm Turnbull for his nation's health care system.

Australia has universal health care. See 34-second clip.

INSIDE HHS

An upstairs-downstairs divide on an uneasy day. Inside the Humphrey building, Trump's political beachhead staff and appointees spent the day alternately fretting about the vote in public and celebrating in private, tipsters tell PULSE.

Career staffers who joined during the Obama administration, on the other hand, say that they're weary of the uncertainty — and constant questions about the future of their programs — and many have tried to ignore the effort until it reaches a more serious stage in the Senate.

"Appalling as it is that it passed the House, most of us see a long road ahead," one CMS staffer who works on an Obamacare-related project said. "I feel like I did more therapy hotline with friends outside than worrying myself."

… HHS Secretary Tom Price will be on "Meet the Press" on Sunday.

Trump taps Matthew Bassett to be HHS assistant secretary for legislation. The office is the key conduit between the department and Congress.

Bassett is currently senior vice president for government relations at myNexus, a Tennessee-based digital health care company that offers a platform for doctors to remotely monitor their patients’ health. Bassett previously ran his own consulting firm for several years, worked for public relations firm ReviveHealth and led national state government affairs operations for DaVita, the largest U.S. dialysis company.

He also served as a senior health care adviser to former Kentucky Gov. Ernie Fletcher and as a senior legislative assistant for Rep. Pete Sessions (R-Texas)

Senate to hold procedural vote on Scott Gottlieb on Monday. If that cloture vote on Trump's FDA nominee is successful, the Senate could then gain as much as 30 additional hours of debate until final confirmation, which is likely to occur early Wednesday.

The Senate HELP Committee voted 14-9 last week to advance Gottlieb's nomination with two Senate Democrats breaking with their party to support him.

WHAT WE'RE READING

The world isn't ready for the next pandemic, Bryan Walsh concludes at TIME magazine. More.

Wired's Adam Rogers looks at the pending collision of genetic testing and health policy, suggesting that the House GOP health plan would make your genes "a pre-existing condition." More.

Health law expert Nicholas Bagley's review of the Upton amendment, a crucial piece to winning over GOP moderates: "incoherent, arbitrary, and technically complex." More.

Limiting visits from pharma reps to doctors appears to rein in health spending by reducing the number of expensive prescriptions, according to a new JAMA study reviewed by Vice News. More.

Are the AHCA's risk pools really underfunded by $200 billion? Josh Archambault takes a look at Forbes. More.

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