The week that could break the House: Balanced budget and the Medicare 'doc fix'

Next week could very well break the U.S. House of Representatives.

Or, if things go well, the House Republican majority could score two of its biggest legislative victories in quite a while, demonstrating it can govern.

The stakes are high as the GOP plans to debate and approve a budget. It’s a two-step in which Republicans slash spending but maneuver parliamentarily to bolster defense programs, satisfying both fiscal conservatives and budget hawks.

Or, the effort could blow up in the Republicans’ face.

In addition, the House will tiptoe through what has become one of the most-nettlesome votes in Congress: approving a replacement measure to cover the “doc fix” for physicians and seniors who use Medicare.

A failure to approve a plan has the potential to capsize the Medicare system. There is a chasm between what Medicare patients pay doctors and the reimbursement physicians receive from the federal government. The deficit is now around 22 percent. If doctors don’t get that government fiscal putty, they might not afford to see Medicare patients.

That would force the Medicare system into a tailspin, prevent elderly patients from receiving treatment and possibly implode a surfeit of individual doctor practices -- which rely on the government for payments.

A failure to act could be an economic disaster -- to say nothing of a public health crisis.

Conservative Republicans hate the doc fix because it’s not paid for. A current plan could spill an additional $140 billion onto the national debt. But the political consequences of wrecking the Medicare system could be catastrophic.

Let’s start with the budget.

Rep. Tom Price, R-Ga., is the new Budget committee chairman. Price’s initial budget faced trouble as the committee prepped the resolution for floor action next week. Defense-minded Republicans demanded additional money for the military and threatened to vote no on the floor. That phenomenon created two problems. If Price added the defense money in committee, the budget would die there. Fiscal conservatives could have detonated Price’s entire budget, barring it from coming to the floor. However, if Price maintained the austere budget, without directing more money to the Pentagon, a larger group of defense hawks could vote no on the floor, torpedoing the budget there.

Failing to move a budget would be an utter embarrassment for Republicans. GOPers howled for years at Senate Democrats for not adopting budgets -- though Senate Minority Leader Harry Reid, D-Nevada, did shepherd one to passage in 2013. Moreover, failing to adopt a budget could prevent the GOP from reaching what they consider to be the ultimate pot of gold at the end of the rainbow: passing a measure through both bodies of Congress that repeals ObamaCare and perhaps replaces it with something else.

The budget process includes a very special set of provisions called “reconciliation instructions.” Reconciliation is unique parliamentary process that resides in the budget world. It can only be utilized upon enactment of a budget resolution. The quintessence of the Senate is unlimited debate and an unlimited amendment process. That leads to filibusters and 60 vote thresholds to overcome filibusters. But not under budget reconciliation rules.

“Reconciliation” limits debate and amendments. It also entails a simple majority to adopt an item. Right now, the Republican Senate majority is facing all sorts of problems trying to pass a human trafficking bill because of a Democratic filibuster. Senate Republicans floundered for weeks over immigration provisions and Department of Homeland Security funding, stymied by a Democratic filibuster. So adopting a budget is of the highest importance. Failure strips Republicans of the chance of reaching the prize.

“I think the reconciliation language will be a motivating reason to vote for the budget,” said Rep. Jim Jordan, R-Ohio, one of the most conservative members of Congress and a leader of the House’s ultra-right Freedom Caucus.

Still, some Republicans aren’t even drinking their own party’s Kool-Aid when leaders extoll the merits of Price’s budget.

“I don’t know anyone who believes we’re going to balance the budget in 10 years,” claimed Rep. Ken Buck, R-Colo. “It’s all hooey.”

Republicans aim to bring the budget resolution to the floor mid-week. That’s where things could get tough.

If the Republican brass didn’t think it had the votes to pass a garden variety bill, it might just postpone the issue and not bring it to the floor. Or, the leadership might allow the House to debate the issue and halt the process right before the vote.

You can’t do that when dealing with a budget.

Budgets are considered under a provision that enables the House to consider other proposals in lieu of Price’s base plan. Various House groups are expected to offer alternative budgets: the Congressional Black Caucus, the Progressive Caucus, House Democrats, the Republican Study Committee (RSC), etc. Fox News is told that the Freedom Caucus will not offer a budget. The House treats these budgets as “substitute amendments.” In other words, the substitute yanks out all of the text of the underlying Price budget and simply inserts new language in place. That’s a substitute.

However, there’s a problem when considering a substitute: If the House adopts a substitute before the base resolution (in this case, Price’s budget), that budget wins. The entire process comes to a screeching halt and members never get to Price’s outline.

One senior Republican leadership source told Fox “we’re screwed” if the House OK’s the RSC budget or anything. The source argued the top-line spending numbers in any budget more conservative than Price’s are too low and could have drastic fiscal impact on the entire federal government.

“That messes up everything,” the source said.

So the Republican leadership must trod carefully here. Leaders must be certain about the whip count ahead of time. The GOP whip operation has been the source of much anxiety recently. Nearly every vote of consequence has been dicey, based on some very wobbly vote counts. The GOP majority can’t put a budget on the floor and allow an uncertain whip tabulation to undermine the Price prototype.

Republicans have successfully moved major items when they’ve relied on votes from Democrats. But budgets are partisan documents. They’re not going to get any assistance this time from the other side of the aisle.

“I’m confident that Democrats will oppose this budget,” said Maryland Rep. Chris Van Hollen, the top Democrat on the Budget committee. “You can never say for sure. But last year, it was 100 percent.”

This is complicated by the gambit of House Speaker John Boehner to somehow add an amendment to the budget in the Rules Committee on Monday to satisfy the defense hawks. The defense amendment could mean fiscal conservatives bolt. But the addition of the amendment lures defense-minded members. The vote count can’t be shaky with so many moving parts.

Boehner understands the challenge.

“Completing work on a budget is always one of the hardest things we do each year,” said the Ohio Republican. “We've walked everyone through it and we think we're in a good place.”

Republicans are betting that the defense money effort, coupled with the goal of getting to reconciliation to tackle ObamaCare, could be the magic elixir to lug a budget across the finish line.

“We’re trying to work with our members to make sure that they fully understand the ramifications of the direction that we go,” said Rules Committee Chairman Pete Sessions, R-Texas. “That’s a stark difference  from past years when we did not effectively make sure all the members understood the options and the ramifications.”

But are those ramifications enough to quell an infuriated right wing?

“They said they were no longer going to make substantive changes in the Rules committee,” barked Rep. Mick Mulvaney, R-S.C. “That lasted a week. Now we’re making substantive changes.”

Before the leadership settled on the defense gambit, Mulvaney railed against the defense spending, noting it was “off-budget” and the “worst way to spend money. We’re spending it because we can.”

After Republicans settled on the defense strategy, that further inflamed Mulvaney and the right flank.

“I’m more angry than I was yesterday,” he said.

This is where the doc fix and the budget meet -- especially when it comes to additional money that isn’t offset.

“At the same time we're going to balance the budget in ten years, we're adding $130 to 140 billion to the deficit,” Rep. Raul Labrador, R-Idaho, said of the doc fix plan.

In other words, how can the House adopt a budget that is purportedly balanced, yet simultaneously move a doc fix which piles on additional debt? Price’s advocates argue there are other budgetary cost-savings which help cover the cost of the doc fix as well as additional expenditures. But that might not satisfy House conservatives who could vote nay.

That’s where Democrats come in.

Democrats won’t assist Republicans on the budget. But the bipartisan talks led by Boehner, House Minority Leader Nancy Pelosi, D-Calif., and a host of other key players, appears to have forged a compromise. It could ensure Medicare reimbursements and sidestep a health and economic calamity. Democrats are expected to cover a substantial number of Republican “noes” on the doc fix, perhaps ushering that plan to passage.

“There was an opportunity that presented itself to work in a bipartisan way to find the appropriate spending offsets. The door opened and I decided to walk in,” Boehner said.

It’s far from done, but most bipartisan sources think the doc fix is in better shape than the budget. Last year, Republicans engineered a controversial tactic to approve the doc fix. Without telling members what was afoot, the House slyly adopted a year-long doc fix patch without full roll call vote, sliding the measure through before anyone even knew what was going on.

“We won’t do that again this year,” said one senior Republican source.

However, at least that parliamentary contrivance worked. There’s anything but certainty in the coming days. The doc fix remains a challenging vote. Who wants to vote against seniors from getting treatment under Medicare? And who wants to further explode the deficit?

The coming week is a good glance at how Boehner and his leadership team might operate for the rest of this Congress. On one hand, Boehner faces a test at holding Republicans together on a partisan effort like the budget. On the other, the doc fix unveils a frontier in coalition building. If successful, the development of bipartisan coalitions could help fund highway programs, raise the debt limit and keep the federal government operating this fall. Success could telegraph the GOP strategy for the rest of the Congress.

“We really need to put a win on the board,” said one senior House Republican aide of the doc fix and budget experiments.

We’ll know soon if GOP leaders advance to the next round, or break the House.