Major medical organizations, including the American Medical Association (AMA) and the American Hospital Association, appeared united in opposition to the American Health Care Act (AHCA), yet House Republicans passed the Affordable Care Act (ACA) replacement bill without making any changes those groups wanted.

Healthcare leaders may be asking why the industry’s opinion isn’t being considered, in contrast to their involvement in crafting the ACA. Julius Hobson Jr., former director of congressional affairs for the AMA who now works for law firm Polsinelli, told HealthExec there’s an obvious answer: campaign promises.

With the AHCA now in the hands of the Senate, Hobson spoke about the next steps, like how the Senate will change the bill, if there’s any way to get Democratic votes and how the whole process could fall apart.

HealthExec: It seems like nearly every major healthcare association has come out against the AHCA. Why didn’t their opinions have an impact on lawmakers?

Julius Hobson Jr.: What you have is a situation where Republicans have campaigned for seven years saying that when they got the trifecta—meaning House, Senate and White House—they would vote to repeal and replace the Affordable Care Act. So it’s about trying to deal with campaign promises.

Quite frankly, I think the way it was done in the House was not necessarily about the policy, but about trying to meet those campaign promises, so they moved it as quickly as they could as soon as they got the votes.

Do those same associations have a better chance of being heard by the Senate?

Yes. All of this attention in the House was placed on the essential health benefits and pre-existing conditions. In the Senate, the concern was about the Medicaid provisions and the Medicaid cuts, and there were Republican senators who said immediately, ‘I’m not voting for that.’ So even before you got to adding the amendments on high-risk pools and those other discussions, it was dead in the Senate as written.

Another thing to look at is in using the budget reconciliation process. When the committees marked up their versions of the bill, they did so with the Byrd Rule in the Senate in mind. With the addition of those three amendments, I don’t know if those would survive a Byrd Rule challenge.

That’s going to be a question for the parliamentarian’s office. If not, they’ll be subject to a budget act point of order, and 60 votes would be required to keep them in.

We’ve got a long way to go. Anything that the Senate does is certainly going to be to the left of what the House has done—and everybody knows it.

That would mean a conference committee between the House and Senate to work out a compromise. What are the chances the House rejects the less conservative Senate version and the legislation dies?

If you ask me for my vote, that’s where it is now.

One of the things about the House bill is the Medicaid cuts help to pay for the tax cuts. That’s why you have some people talking about the House bill really wasn’t a health bill as much as an income transfer bill. In order for something out of the Senate, it will have to restore a substantial amount of those Medicaid dollars. Also, because of the Byrd Rule, I don’t know if the high-risk pool stuff would survive.

If a lot of the Medicaid cuts get restored and the risk pool issues don’t survive, I don’t know how the House and Senate can reconcile their differences and pass something that the president can sign.

In the House, you had more room in the negotiation process. In the Senate, looking at a 52-48 situation, the Republicans can lose two votes. Well you have three Republicans in the Senate—(Mike) Lee, (Ted) Cruz and (Rand) Paul—who support flat repeal. You’ve got other senators, like (Lisa) Murkowski and (Rob) Portman, who are going to say those kinds of cuts to Medicaid are going to harm our constituents.

It’s just hard to figure out how they can reconcile their differences. The one thing you do know is what passed the House isn’t going to pass in the Senate. Period.

Are there any likely changes which could get Democratic votes on board?

Not a chance. I don’t see that happening. The question for the majority in the Senate is do they try to engage Democrats. If they do, they’ll get a product that will be even more moderate than what the House passed, and that may make settling the differences between the two bodies almost impossible.

What should doctors and hospitals expect in terms of a timeline—how long does the Senate really have to get this bill passed?

Here’s where it gets a little complicated.

They used the budget reconciliation process with a fiscal year 2017 budget resolution. The president hasn’t submitted his full budget. When the Congress enacts a fiscal year 2018 budget resolution, if it hasn’t completed actions on the FY2017 budget reconciliation bill, the reconciliation bill dies the moment they do a FY2018 budget.

The Senate maybe has two months. They would need to get it done probably by the end of June, if not sooner, because the FY2018 budget process has got to move and they want to move to tax reform.

If we get to August and this isn’t done, I don’t know how you make it, because the first set of primaries for the 2018 elections occur in March. So they don’t have a lot of time.

So how worried should hospitals and health systems opposed to this legislation really be?

I’ve been in this business for 45 years. You never stop worrying until the Congress is over. This is an issue that if you’re worried about it, just stay with it until it’s done, and it’s just not done.