The Republican Party's mad dash to repeal the Affordable Care Act and replace it with a new law, the American Health Care Act, is being driven by two big, related considerations: the calendar, and the Senate's budget "reconciliation" rules, which allow the Senate to pass certain pieces of legislation with a simple majority. The AHCA was written narrowly to fit within the constraints of the reconciliation rules, and whether it does will be partly determined by how much the Congressional Budget Office estimates the bill will cost.
Without reconciliation, the already endangered bill won't clear the Senate. Without major changes to satisfy GOP conservatives, it may not pass the House. President Trump and some congressional Republicans have come up with a solution to this conundrum: Ignore the CBO and overrule the Senate parliamentarian, who determines which measures can be passed through the reconciliation maneuver, as long as 60 senators don't overrule her advice. This wouldn't be so much "working the refs" as ignoring them, and it would likely throw Congress into chaos.
The CBO — led by Republican appointee Keith Hall — is expected to estimate that the AHCA increases the budget deficit and cuts at least 15 million people off health insurance. The new GOP line is that CBO economists and statisticians can be ignored because their projections just aren't very good. Their main exhibit: The CBO score for ObamaCare. "If you're looking to the CBO for accuracy, you're looking in the wrong place," White House Press Secretary Sean Spicer said Wednesday. Rep. Greg Walden (R-Ore.) made a similar argument on Hugh Hewitt's radio show. (The CBO's ACA projections were actually "reasonably accurate," according to a 2015 Commonwealth Fund report.)
"I have no idea what the CBO report will say," said Sen. Bernie Sanders (I-Vt.), "but I find it amusing that the right-wing Trump administration would try to cast doubt about the integrity of that report when it was the right-wing Republicans who handpicked its director."
Sen. Ted Cruz (R-Texas) and House conservatives, meanwhile, are arguing that Vice President Mike Pence, in his role as presiding officer of the Senate, can simply override any unfavorable reconciliation ruling by parliamentarian Elizabeth MacDonough. Cruz said he's been discussing that plan, which would allow the GOP to scrap things like ObamaCare's ban of discrimination based on pre-existing conditions, with "a number of my colleagues." Freedom Caucus chairman Mark Meadows (R-N.C.) and vice chairman Jim Jordan (R-Ohio) promoted the idea with Trump over lunch on Thursday.
It's not clear if either of these maneuvers will work, but that's where the fight is going.