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WASHINGTON The health care plan barely approved by Republicans in the House faces even more difficult challenges in the GOP majority Senate, based on interviews with several senators.

The contentious issues are similar: the cost of the plan, how to pay for it, coverage of pre-existing medical conditions for the sick and disabled, subsidies to help people who cant afford market rate premiums, co-payments and deductibles.

Republican Sen. James Lankford of Oklahoma said he remains hopeful the Senate can fashion legislation that will overcome divisions among his GOP colleagues and also appeal to the more conservative House.

I think well get there, said Lankford, a member of the influential Senate Appropriation Committee. We have to.

But Lankford said the road ahead faces tough going because the House plan, embraced by President Donald Trump, wont provide sufficient subsidies for low-income people to afford insurance.

It would no longer consider age or income in determining the amount of individual subsidies, a change the nonpartisan Congressional Budget Office estimates would mean millions of poor and older Americans not yet eligible for Medicare lose their insurance.

Lankford, a fiscal conservative, said in a statement after a brief interview he wants to make sure no individual ends up in worse shape.

Reflecting the philosophical divide among Republicans, senators such as Rand Paul of Kentucky want to strictly limit the governments involvement in health care, and are opposed to any subsidies.

Even though the House plan lowers the subsidies, Paul said in an interview on Fox News hes not that interested in subsidizing the profits of insurance companies. They make a lot of money.

Paul has a plan to allow individuals to group together like company employees to negotiate with insurers to get the best price and coverage -- a strategy he said will lower premiums and protect people with pre-existing conditions without government mandates.

The debate over government subsidies was also a sticky issue last month for House Republicans before they came together to narrowly approve a compromise.

House Speaker Paul Ryan canceled the initial vote on the GOP plan over lack of enough support from conservative and moderate lawmakers. Changes were made and the revised bill, with a push from Trump, received 217-213 approval last week. Twenty Republicans dissented.

Senate Republicans, who hold a slim two-vote majority, can only afford to two defections in order to pass a health care plan.

That means finding common ground not only subsidies but also protecting coverage of pre-existing conditions and Obamacares essential health benefits such as maternity, mental health and prescription drugs.

The House plan repeals Obamacare but continues the laws ban on insurers denying coverage to people with pre-existing conditions. But the concern is it also allows states to let insurers charge people with medical issues higher rates if they have a lapse in coverage -- a hitch health advocates say penalizes lower-income individuals who interrupt their coverage due to cost or other reasons.

Sen. Shelley Moore Capito, R-W.V., said in an interview shes concerned the House plan isnt clear enough in protecting people with medical conditions. Shes also troubled that the House bill rolls back Medicaid assistance over time in the states that chose to expand it under Obamacare.

Capito said 180,000 West Virginians get insurance through expanded Medicaid.

A lot of them have addiction issues and drug abuse issues, she said. If (the program) goes away, there will be tragic consequences -- such as overdose deaths that occur more frequently on a per capita basis in West Virginia than any other state.

The federal government now picks up nearly all of the cost for the 31 states that expanded Medicaid to cover low-income people who make too much to qualify for the traditional program.

Marie Gordon, spokeswoman for Sen. Johnny Isakson, R-Ga., said hes looking at the other side of the Medicaid coin states like Georgia that did not expand Medicaid having to pay for states that did. She also said, however, that Isakson would not be supportive of legislation that fails to ensure affordable coverage for those with pre-existing conditions.

Sen. Pauls plan would end support for the Medicaid expansion.In a phone call with reporters this week, Sen. Chuck Grassley, R-Iowa, said hes concerned about preserving traditional Medicaid. A spokeswoman for Grassley said later he hasnt come to a position on expanded Medicaid.

The House plan continues to fund Medicaid expansion for individuals already in the program, but beginning in 2020, the states would get less for new recipients. Capito said her state faces a $500 million budget deficit this year and is in no shape to make up the difference.

In March, she and three other Republican senators from Medicaid expansion states, including Ohios Rob Portman, wrote Senate Majority Leader Mitch McConnell announcing they wont support a plan that doesnt include stable funding for Medicaid expansion.

A group of 13 ranking Senate Republicans, including McConnell, has been appointed by the majority leader to work on Medicaid and other conflict issues. It has been criticized for no women members, though Capito met with the group this week.

Ultimately, said Grassley, Republicans have no choice but to come together on a health care legislation because theyve promised for years to repeal Obamacare. We have to deliver, he said or risk voters losing confidence in their government.

More importantly, he added, is the potential loss of insurance companies offering subsidized policies Iowa because the present health system is failing.

Kery Murakami covers Washington for The Eagle-Tribune and its sister newspapers and websites.

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Republican senators search for deal on health care - Eagle-Tribune