WASHINGTON — It took plenty of blood, sweat and tears for Republican leaders to finally push their health care bill through the House last week. Don’t expect the process to be less complicated in the Senate, though more of the angst in that more decorous chamber will likely be behind closed doors.

No one expects a new bill to be written quickly, but Senate Majority Leader Mitch McConnell, R-Ky., has started a process for producing one. Republican senators have made clear their measure will differ markedly from the House legislation, which has drawn criticism from Democrats who see it as a pathway to winning a House majority in the 2018 elections.

“This process will not be quick or simple or easy, but it must be done,” McConnell said Monday.

McConnell’s groupMcConnell dislikes surprises and drama. Both characterized the House’s chaotic four months of work on its bill, which saw revolts by conservatives and moderates derail initial versions and humiliate President Donald Trump and Paul Ryan, R-Wis.McConnell has included himself in a group of 12 GOP senators essentially tasked with privately producing a bill that can pass the Senate. Republicans control the chamber 52-48.Democrats are virtually certain to unanimously oppose the effort to repeal much of President Barack Obama’s health care overhaul. So Republicans are using a special process preventing a Democratic filibuster. McConnell will need 50 GOP votes to pass a bill, a tie Vice President Mike Pence could break.That means McConnell can lose just two Republicans.Sen. Rob Portman, R-Ohio, is among Republicans whose states dislike the Medicaid cuts because they’d face a wave of constituents losing coverage under the health care program for the poor. The House would end the extra federal money states get for new beneficiaries under Obama’s Medicaid expansion by 2020, and some GOP senators want a delay.Much Medicaid money is used to combat the illegal use of addictive opioid drugs. That’s another reason for GOP senators from hard-hit Midwestern and Northeastern states to oppose such cuts.Obama’s law helps millions buy private insurance with federal subsidies geared to income and policy premiums. The House instead links its aid to age, with older people getting larger tax credits. Thune and others want to shift the subsidies more generous to lower earners.In addition, the filibuster-free process Republicans are using requires that legislative provisions be related to raising or decreasing the federal deficit, and not primarily driven by policy changes. Conservative health care analyst James Capretta says the odds for survival “are low” for House language letting states permit insurers to boost premiums on some people with pre-existing conditions.Also in jeopardy: a provision forbidding consumers to use federal subsidies to buy insurance covering abortion.The Senate parliamentarian will decide whether provisions must be stricken from the bill. The Senate could override that with 60 votes.

Possible changes