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3 ways Senate Republicans can pass Obamacare repeal

And four ways they could fail.

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Whatever health care bill Senate Republicans produce in secret will have to solve a very basic math problem: Can it add up to 50?

By all accounts, Senate Majority Leader Mitch McConnell (R-KY) is agnostic about the actual policy of the bill his chamber is drafting. His only concern is whether it can get 50 votes, the bare majority it needs under the “budget reconciliation” rules Republicans are using to avoid a Democratic filibuster. He can lose only two of the 52 members of his conference.

The secretive drafting of the Senate’s plan has allowed speculation to flourish. The truth is we just aren’t sure yet what’s going to be in the bill or how it will differ from the House legislation that was projected to lead to 23 million fewer Americans having health insurance and $830 billion in Medicaid cuts.

McConnell is pressing ahead for a vote by July 4, the Wall Street Journal reported, though nobody is sure whether he actually has the support he needs. His timeline will give senators as little as one week, maybe less, to review a bill overhauling one-sixth of the US economy.

With that razor-thin margin for error, it seems like it could go either way. Senate Republicans could finally coalesce around a plan to achieve their long-sought goal of undoing Obamacare — or they could fail spectacularly.

Here are three possible paths that could lead the Senate to vote to overturn Obamacare, and four that end with them derailed along the way.

Why the Senate will pass their health care bill:

1) McConnell appeases the moderates on Medicaid and insurance regulations.

The more moderate Republicans in the Senate had some big problems with the House bill, which rolled back some of Obamacare’s insurance protections, its financial aid to help people purchase private insurance, and overhauled Medicaid, the nation’s biggest insurer.

They thought the Medicaid cuts, including an abrupt end to Obamacare’s Medicaid expansion in 2020, were too harsh and they opposed rolling back the law’s protections for people with preexisting medical conditions.

McConnell has moved in their direction on those issues, proposing a more gradual three-year phaseout of the Medicaid expansion and keeping the Obamacare rule that prohibits health plans from charging sick people more than healthy people.

In turn, some of the Senate moderates thought to be most difficult for McConnell to get have said positive things about the emerging plan.

“It’s clear from the outline that I have seen of the Senate’s — where there were a lot of question marks, so they’ll be filled in — it’s quite different from the House bill, and I think that’s a good thing,” Sen. Susan Collins (R-ME) told reporters last week.

If McConnell wins over all the moderates, then he can lose the most conservative senators — Rand Paul of Kentucky and Mike Lee of Utah — and still pass the bill.

2) He threads the needle with enough moderates while holding the right flank.

McConnell could also go in the opposite direction and sacrifice two moderate votes, likely to be Collins and perhaps Sen. Lisa Murkowski (R-AK), who told me last week that she was very frustrated with the House bill and the Senate’s secretive process.

In that case, he would have to win over the conservatives. The Hill and Axios reported Monday that the Senate could end up including even lower Medicaid spending caps than the House bill did, a provision that could help appease the right flank. Though they tend to be more ideological than the moderates, conservatives can be practical too.

"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 told me last week.

McConnell could keep a few of the moderates worried about Medicaid on board by offering additional funding for the opioid crisis — Sens. Rob Portman (R-OH) and Shelley Moore Capito (R-WV) are asking for $45 billion over the next 10 years — and still get to 50 votes without Collins or Murkowski.

3) They’re Republicans and it’s a Republican health care bill, stupid.

The power of partisanship helped the House move from disastrously short on votes to narrowly passing a bill over the course of one month. The same dynamic could push senators to get in line; McConnell told them privately that they would be paving the way for single-payer health care if they didn’t pass this bill.

Take Sen. Dean Heller (R-NV), who faces the most difficult reelection campaign next year. He represents an increasingly blue state that expanded Medicaid and where the Republican governor has criticized the House bill. That’s a lot of reasons to vote against any similar plan.

Nevertheless, when I asked Jon Ralston, editor of the Nevada Independent and the dean of the state’s political reporters, if Heller could still end up supporting the bill, he cited partisanship as one reason Heller might come around (emphasis mine):

Politics of next year say he should vote against it because of the polling here that shows how unpopular it is. Then again, he might lose the base if he votes no, which has to concern him. Dilemma for many Republicans, but especially for him because he is so vulnerable.

Seth Masket, a political science professor at the University of Denver, made a similar point when I asked him why Sen. Cory Gardner (R-CO), another swing vote from a swing state, might vote for the bill.

“Voting for the health care bill could be damaging to him in his next reelection race,” he said, “but voting to kill it could hurt him in the primary and help draw a challenger.

So while many senators have grumbled about the GOP’s plan, when push comes to shove, it might prove too hard for them to vote against Obamacare repeal and they’ll set their concerns aside to back the bill.

Why the Senate won’t pass their health care bill:

1) It’s political suicide for too many senators.

The House’s bill is devastatingly unpopular, and the Senate might not do much to soften its worst impacts. Voting for such an unpopular bill, on an issue as politically powerful as health care, could be untenable for too many Republican senators. Heller and Sen. Jeff Flake (R-AZ) could face tough reelection races next year, even though the overall map is worse for Democrats, and others are already looking ahead to 2020.

Public Policy Polling came out with some horrifying numbers for Heller on Monday: 51 percent said they opposed the House bill, and 45 percent said that they’d be less likely to vote for Heller if he backed a similar bill. He trailed a generic Democratic opponent 39 percent to 46 percent.

Other Republicans face uncertain political futures. Flake is also up in 2018, in a state that’s trending blue and in what could be a Democratic wave year. Collins is reportedly considering a run to be Maine’s governor in 2018. Gardner faces voters again in 2020, in another increasingly Democratic state that expanded Medicaid under Obamacare.

These senators could simply decide their careers would be doomed if they were to support legislation as unpopular as what Republicans are working on.

2) McConnell won’t give enough on Medicaid for the moderates.

McConnell has acceded to some of the moderate demands on Medicaid, but not all of them. If just three of the 20 Republicans who represent Medicaid expansion states refuse to support it, they could sink the bill. Portman, Capito, Murkowski, and Gardner are some of the senators most focused on the Medicaid provisions.

McConnell, according to reports weeks ago, was proposing a three-year phaseout of Medicaid expansion. Portman and the others countered with a seven-year phaseout. Yet according to Monday’s report, McConnell is still set on a three-year phaseout. Can those senators really talk themselves into voting for the bill if they don’t get any more concessions?

On top of that, they could also balk at the lower spending caps on Medicaid that McConnell is reportedly proposing. Portman has said repeatedly that he didn’t want any deeper Medicaid cuts than the House had already included.

Capito also told me last week that one of her top priorities is protecting people on Medicaid.

“Unless I’m confident we can do that, I don’t know how we can move forward in good conscience,” she said.

3) The conservatives revolt because McConnell moves too far to the middle.

Outside conservative groups have been agitating over the Senate’s plan, arguing it is moving too far toward the middle — a likely sign that conservatives inside the Senate are also unhappy. They’re seeing McConnell delay some of the Medicaid cuts and show he’s willing to keep more of Obamacare’s regulations.

Paul and Lee are outwardly frustrated with the bill, and Sens. Ted Cruz (R-TX) and Tom Cotton (R-AR) could join them. They saw the archconservative House Freedom Caucus hold out for more concessions in the lower chamber, and they may decide they should do the same.

“If they don’t have the votes to pass it, they’re gonna have to negotiate with people,” Paul said last week.

Cruz, a member of the working group that’s negotiated in closed-door meetings since early May, has largely stayed positive in his comments about the Senate’s talks. But in more recent days, he has started to sound a bit more pessimistic.

“We’re not there yet, and we’ve got to get it right,” he told me last week.

4) The Senate’s rules make the bill untenable for too many senators.

The “budget reconciliation” process Senate Republicans are using to pass their legislation with a bare majority places some restrictions on what McConnell can include in his plan. I broke it all down last month, but the gist is that the bill is supposed to be limited to policies that directly affect federal spending or revenues.

Those rules could hamper McConnell’s ability to thread this political needle. Nixing some of Obamacare’s insurance regulations might not comply, which could be a deal breaker for conservatives like Cruz who are fixated on lowering premiums. They think unwinding those regulations are the best way to do it.

Or Republicans might not be allowed to defund Planned Parenthood under the reconciliation rules, another potential problem for conservatives. The House bill had also prohibited its financial assistance for private insurance from being used on plans that cover abortions. That’s another policy that could be at risk under the Senate rules, which risks alienating anti-abortion senators.

Negotiations with the Senate parliamentarian, who will make these decisions, are private, so we don’t know yet how real these problems are. But they are yet another complicating factor for McConnell and his pursuit of 50 votes.