3 roadblocks for the Senate's last-ditch health care negotiations

Millions of Americans have a huge financial stake in the next few weeks of Senate negotiations over the Affordable Care Act's enhanced tax credits.Why it matters: Absent a deal, health care coverage costs could double next year for people who rely on ACA exchange plans.Zoom in: Senators from both parties are cautiously optimistic that a bipartisan deal to extend the subsidies is possible. But there are significant political headwinds.Early bipartisan and bicameral negotiations have been ongoing over what to do with the expiring ACA tax credits, which were increased during the COVID-19 pandemic. The Senate Finance Committee will hold a key hearing on health care costs on Wednesday, setting the stage for a public debate that has largely been behind closed doors.Yes, but: While the Senate could give bipartisanship a try, prospects for a deal are even dimmer in the House and the White House, where President Trump has been advocating his own proposal to send money directly to consumers. Democrats, whose starting position is a clean subsidy extension, feel they have a stronger political footing on health care amid concern about rising costs.What to watch: Most Senate Republicans have been adamant that any deal to extend the tax credits will need to be short-term and require "reforms." Income caps: Conservative Sen. Roger Marshall (R-Kansas) told Axios he could see himself supporting a deal if an income cap was placed back on the enhanced subsidies. Sen. Jeanne Shaheen (D-N.H.) has said such a change is reasonable.Fraud prevention: Republicans have raised concerns about $0 premium plans, which they say allow fraudsters to sign people up without their knowledge, costing the government more money. One idea being floated is a low-cost premium, such as $10.Hyde amendment: "We're not doing something without the Hyde amendment attached," Sen. Katie Britt (R-Ala.) told reporters last week, an argument many GOPers agree with. The hot topic of abortion has the potential to derail any bipartisan compromise.Who to watch: In this new phase, the focus is shifting away from the small bipartisan gang that held talks on reopening the government. The Senate Finance Committee, led by Sen. Mike Crapo (R-Idaho), is expected to lead the negotiations — with Health, Education, Labor and Pensions Committee (HELP) members also closely involved, multiple sources familiar with early talks tell Axios.Sen. Ron Wyden (D-Ore.) — Finance's ranking member — is a key player on the Democratic side, along with Senate Minority Leader Chuck Schumer (D-N.Y.). A Schumer spokesperson said: "The bill Democrats bring to the floor will be a caucus product."Sen. Bill Cassidy (R-La.) chairs HELP but is also a member of Finance. He is passionate about health care issues, up for reelection next year and a trained physician. He is pushing a plan he says fulfills Trump's call to send the subsidy money to consumers directly, by filling flexible spending accounts. Other key voices to watch include Sens. Marshall, Ron Johnson (R-Wisc.), Jon Husted (R-Ohio) for Republicans and for Democrats Sens. Shaheen and Maria Cantwell (D-Wash.). Between the lines: Even if the minimum 13 Senate Republicans help pass a deal, Speaker Mike Johnson (R-La.) will not guarantee a vote in the House. He can also use procedural moves to evade a discharge petition vote before the end of the year.Plus, Trump would need to sign off. His history on health care is full of contradictions, but his recent Truth Social posts have emphasized problems with the ACA — not a need to continue the expiring tax credits.If no bipartisan deal comes together in the Senate, Republicans are expected to put forward their own proposal to receive a vote and give their members something to support, to lessen pressure to back the Democratic plan.What they're saying: Sen. Chuck Grassley (R-Iowa), leaving a meeting of Finance Committee Republicans on Monday, said no "consensus" exists on what to do on health care, but he thinks a deal is possible in the next month.Sen. Jim Justice (R-W.Va.) said he'll "be open-minded," adding, "Let's see how all this plays out."

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