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If Senate Republicans vote to repeal Obamacare, this is how it'll happen

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Weeks of secret negotiations and leaked proposals to the media haven't changed one fundamental fact about the Senate's health care plan: It's all about the path to 50 votes.

The math is still really hard. But I think Senate Majority Leader Mitch McConnell's game plan is coming into view.

Every health care lobbyist and congressional aide I've talked to has said McConnell is totally agnostic about the policy itself. He just wants the bare majority that Republicans need to pass their bill, with Vice President Mike Pence breaking the 50-50 tie.

That leaves little margin for error, as there are only 52 Republicans. So McConnell has only two votes he can afford to lose — and given the objections to the House bill from the middle and the far right, it was supposed to be too hard for Senate leaders to craft a plan that would win over both sides.

Based on the past week of talks, McConnell seems to be trying to sweep the middle — winning over centrists like Sen. Susan Collins rather than vying for the support of Sen. Rand Paul, the Republican most bent on full Obamacare repeal.

On two key points, per leaks to the press, McConnell seems to be willing to moderate the Senate's plan compared with the House bill:

  • He's proposed a three-year phaseout of Obamacare's Medicaid expansion, rather than the House's abrupt cutoff. Senators representing expansion states countered with a seven-year phaseout. I'll bet you a beer they end up at five.
  • He's proposed, contra the House bill, that states would not be allowed to waive Obamacare's prohibition on insurers charging sick people more than healthy people.

The impact of any such plan would likely still be millions fewer Americans having health insurance, billions of dollars cut from Medicaid, and the elimination of the essential health benefits requirement, which is crucial to making sure health insurance covers what people actually need.

But those concessions would probably soften the Senate bill compared with the House plan. That could give more moderate senators the cover they need to back the bill. I would note that President Trump reportedly told senators today that the House bill was "mean" and the Senate plan should be more generous.

A big group of Republican senators represent states that expanded Medicaid, led by Ohio's Rob Portman, and they seem to be inching closer to supporting the bill. Collins, probably the most moderate senator, told me a month ago that she was worried about people with preexisting medical conditions — and now McConnell is giving her a fig leaf, by preventing states from waiving a key protection for those people.

Collins said Monday that the Senate plan was "far superior" to the House bill, though she still had concerns, per the Hill's Peter Sullivan.

At the same time, conservatives on and off Capitol Hill are increasingly agitated about the direction of the Senate plan.

By compromising on Medicaid expansion, "the Senate majority leader is essentially surrendering to moderates in his conference and ignoring grassroots conservatives," FreedomWorks president Adam Brandon said in a statement Tuesday.

"I'm not for any Republican plan that involves any kind of new entitlement program," Paul told me Tuesday. He criticized the new tax credits the GOP wants to create to help people buy private insurance, for that reason, and the big pot of money Republicans are proposing to stabilize the insurance market by funneling money to health insurers.

"If you told me I couldn't repeal everything and some of Obamacare would remain, I would vote for that as an imperfect bill," Paul said. "But I'm not voting for one that has new Republican entitlement programs — like that stabilization fund they're talking about is a Republican entitlement program for a billion-dollar insurance industry."

Paul sounds like a "no" then. Sen. Mike Lee (R-UT) could join him. This is the key distinction about the Senate debate, though: Moderates have the numbers, while there are only a handful of die-hard conservatives on health care.

At that point, McConnell would need to hold on to conservative Sen. Ted Cruz, who has staked his reputation on working with leadership on this bill, and then sweep the moderate side of his ledger in order to get 50 votes.

It might prove too difficult. Sen. Lisa Murkowski (R-AK) is clearly peeved about the whole situation. "I have no idea if we even have a bill," she told reporters on Tuesday. "I learn more from you all."

Collins could still balk too. Divisions over abortion and funding for Planned Parenthood could be too big to bridge. Leadership might try to give something to conservatives — perhaps on those issues — that drives away these moderate senators.

But based on the recent trend in negotiations, this looks like the play McConnell is making.

Chart of the Day

IQ Media

Health care is not the top story these days. The chart above, tweeted by Vox's Jeff Stein, tracks the mentions of health care on cable news over the past few months. That trendline worries progressive activists. Look for more on this from Jeff tomorrow.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

  • "John Kasich Backs Slow Medicaid Rollback, but With More Money": “Ohio’s influential Republican governor, John R. Kasich, said on Monday that he could accept a gradual phaseout of the expansion of Medicaid under the Affordable Care Act, but only if Congress provides states with more money than the House health care bill included and more flexibility to manage the health program for the poor.” —Robert Pear, New York Times
  • "ObamaCare insurer expands to three new states": “An ObamaCare insurer will move into three new states while expanding its footprint in six existing markets. Centene announced Tuesday it would enter Kansas, Missouri and Nevada in 2018, while expanding its presence in Florida, Georgia, Indiana, Ohio, Texas and Washington.” —Jessie Hellmann, the Hill
  • "Trump criticizes House health care bill": "President Donald Trump directed Senate Republicans to pass a generous health care bill at a meeting with more than a dozen GOP senators on Tuesday, arguing that the House’s austere health care bill is difficult to defend, according to people familiar with the meeting." —Burgess Everett, Jennifer Haberkorn, and Josh Dawsey, Politico

Analysis and longer reads

  • "Follow The Money: The Flow Of Funds In The Pharmaceutical Distribution System": “Of a $100 expenditure on pharmaceuticals by consumers, roughly $58 goes to the manufacturer and $41 is captured by intermediaries. (Numbers do not sum to 100 due to rounding.) Of the $58 received by the manufacturer, $17 is spent on drug production and the remaining $41 is spent on other expenditures (such as marketing and R&D) or kept as net profit. Total net profit on a $100 expenditure is $23, of which $15 goes to manufacturers and the remaining $8 goes to intermediaries including $3 to insurers, $3 to pharmacies, and $2 to PBMs.” —Neeraj Sood, Tiffany Shih, Karen Van Nuys, and Dana Goldman, Health Affairs

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