The Senate is barreling toward a vote this week on the Republican health care bill, and basically everything is in flux: what’s in the bill, who might vote for the bill, and, of course, whether the bill might pass. It’s a lot to watch in a few days. To help you score along at home, Vox’s Sarah Kliff, Dylan Scott, and Jim Tankersley swiped a cool format from FiveThirtyEight and Slack-chatted through the various political scenarios that might play out.
Hi all, It's the fourth day of what could either be the very short life of the Senate health care bill — or the very quickly decided future of the American health care system
We're been writing a ton about the policies contained in the bill and how they would affect patients, health care providers, taxpayers, etc., but let's step back and chat some raw politics. Mitch McConnell needs to count 50 Republican "yes" votes to pass the bill. Will he get there?
Good morning! That is indeed the question of the hour. TL;DR: I think McConnell gets there but that it might not happen this week.
We are seeing lots of objections being raised to the Senate bill and those have only grown over the weekend. You have Sen. Ron Johnson writing in the New York Times that he wants to bring back restrictions on preexisting conditions and you have Sen. Dean Heller saying he doesn’t like the current Medicaid cuts. And the Senate essentially has three working days to square all these concerns. It’s really, really hard for me to see how this comes together by Thursday. But who knows — I would not underestimate McConnell as legislative tactician.
Right now though, I wouldn’t be surprised to see the vote not happen this week but get taken up a second time right before the August recess. This is essentially what we saw happen in the House, when legislators needed a bit more time to hammer out a deal. That will give legislators a bit more time to digest the bill make some tweaks.
Dylan, you’re our man on Capitol Hill. How do you game out the odds right now?
My take is: The House debate showed us that Republicans are really eager to get to “yes” to repeal Obamacare. My assumption all along has been that it’s at least possible Mitch McConnell can win over holdout votes with some token gestures. Maybe Rob Portman and Shelley Moore Capito get $20 billion in opioids funding. Maybe Susan Collins and Lisa Murkowski get a vote to remove Planned Parenthood defunding from the bill. Those are the kind of fig leafs they might be able to sell back home as a good enough reason to vote for this bill.
Obviously, the margin for error in the Senate is much narrower. McConnell can lose only two of his 52 Republicans, and he already has four conservatives opposing the bill, plus Dean Heller. But with the conservatives, I could see a situation where, in the end, they’ll decide it’s better to vote for an imperfect bill than nothing at all. Ted Cruz more or less told me as much recently.
So the margin is thin, lots of senators have lots of reasons to vote against this bill, but I am overwhelmed by the belief that if there is a path, McConnell will find it.
Will it be this week? I don’t know. I do genuinely think he’s eager to move on to other issues and, if he concludes that there simply isn’t a plan that gets 50 votes, he’d rather put it up and let it fail so he can be done with health care.
The short version of this is: It really feels like a 50/50 bet right now. Even smart Republicans I talk to think so.
One thing that feels very telling to me is what happened in the wake of the House’s first failed vote. Paul Ryan held a press conference, declared Obamacare the law of the land, it seemed like they were folding. But it turned out that wasn’t the case at all.
I completely agree with Dylan that drive among Republicans to repeal the Affordable Care Act is really, really strong. So even if we don’t see a vote from the Senate this week and some claims that they’re moving onto tax reform, I’m going to be pretty skeptical that they can actually walk away from this.
I agree, but here's a counter-argument. I've spent the weekend in Colorado Springs at a big donor retreat for the Koch network. There are a lot of deep-pocketed conservatives here, a lot of policy leaders, and a bunch of GOP senators, including Cruz, Ben Sasse, and Mike Lee. (There are some Freedom Caucus members from the House, too.)
What's striking to me is how not-fired-up pretty much all of them are about the bill right now. It's bordering on ambivalence. The most conservative members have pretty universally declared that the bill before them now is not, in any real sense, Obamacare repeal.
To make it "real repeal," those senators want to roll back a lot more Obamacare regulations than the bill currently does. But that move — which might alienate moderates — could violate the Senate's reconciliation process. If they get a ruling to that effect, and those regulation changes are ruled out … it's easy for me to imagine a bunch of conservatives breaking against this thing.
I do wonder if, by embracing much of Obamacare’s private insurance infrastructure, Republicans have dampened enthusiasm for the bill. It’s basically more conservative Obamacare, a tax cut and a Medicaid cut — and the last bit is not all that popular with a good number of GOP senators.
The counter to your counterpoint would be: The House Freedom Caucus found a way to vote for partial repeal. But the problem is, to your point, it’s hard to see what concession McConnell can give the Senate conservatives without losing way too many moderates. I really don’t see what that fig leaf would be right now.
The “budget reconciliation” rules make it even harder.
My question for you in Koch-land, Jim, is what is the alternative? They obviously realize that Republicans don’t have 60 votes in the Senate and won’t get there any time soon. So what do big Republican donors want: to give up on Obamacare repeal? Would they settle for this bill that is essentially partial repeal?
Also! Since we’re all policy nerds here, I’d be remiss to not bring up what might change about this bill in the next few days. Dylan and I reported this weekend that we expect the Senate to add some penalties for people who remain uninsured. I’m also watching Medicaid funding and expecting some changes there. Anything else from you two?
Opioids funding is the big one for me. The initial Senate bill included only $2 billion in one year, after Portman and Capito — two essential votes — asked for $45 billion over 10 years. That seems like a very obvious place for McConnell to boost the funding to win their support.
These segue us into what I think will be a useful exercise: Some scenarios on how this all might end. Let's toss them out rapid-fire. I'll start, with two from Koch country:
Scenario 1: A conservative stampede. Cruz gets the regulatory amendments he wants, even Rand Paul is happy, and the movement (including Kochs) galvanizes pressure on other senators. In the end, only Heller and maybe Collins vote no. It passes.
1a: A stampede away. The rules are stripped by the Byrd process. Cruz, Lee, and Paul all stay “no” on the bill. Ron Johnson joins them. Heller joins them. Now another half-dozen are free to vote no. In the second of those scenarios, Cruz comes back with a straight-up repeal bill.
I could see your Scenario 1. But Rand Paul seems hard to win, even if he’s left himself some wiggle room to come around. He has said he opposes the bill’s stabilization funding for health insurers — there is no way that’s going to be removed. Heller also seems long-gone. It’d probably be the end of his career if he voted for this. He’s up for reelection in 2018 in a swing state with a very popular Republican governor who opposes the Senate bill.
So if Paul and Heller are “no” votes, my Scenario 2 where it passes is Portman and Capito get their opioids funding and maybe a little less drastic Medicaid cuts, while Lee/Cruz/Johnson get some kind of fig leaf on insurance regulations that brings them around. All of them have been heavily involved in the health care talks over the past month. Are they really going to block this bill, in the end?
Then Collins and Murkowski get their vote to remove Planned Parenthood defunding from the bill. They’d also like softened Medicaid cuts, and keeping the Obamacare infrastructure for the tax subsidies addresses some of Murkowski’s concerns about her state’s high health care costs.
That’s basically a straight flush for McConnell. But that’s how I see it, I think. Moving the bill to the right seems like a dangerous game, unless the moderates fold much easier than we think.
If it fails, I agree with Scenario 1a — everybody is just going to sprint away from it. I think the bill either gets 50 on the nose or it could drop as low as 40. If it’s below 50, nobody who’s on the fence is going to vote “yes” for the sake of voting “yes,” I don’t think.
I think Scenario 2 feels like the most realistic one on the table right now. As Dylan has written, it seems like a lot of these rules changes that folks like Cruz want are not going to be Byrd-able. This includes things like insurance sales across state lines or changing the mandated benefits. But who knows, the Byrd bath works in mysterious ways and maybe this all survives.
I come back to the idea that Obamacare repeal is an alluring prospect to Republicans, and even if it's not their ideal repeal, they will line up behind it. The Freedom Caucus in the House, after all, was able to get behind a bill that still has tax subsidies in the private market. This makes me think they can do the same in the Senate. But I think it’s going to take more than three days to work this out, and for senators to go back to their districts for a week and think about how much they want to pass this bill.
One other interesting political dynamic is how the resistance and July recess play into this. So far the resistance has honestly felt a bit muted. There was a protest at DCA last week, to catch legislators as they left DC, that only attracted a few dozen protesters, according to a Politico story. That was in stark contrast to the hundreds who turned out over the deportation ban. If the bill doesn’t pass this week, then senators will have to go back to their districts and hear from constituents — but weirdly the outrage might be even more muted because the bill didn’t pass.
I'm still not sure how you get an extra vote by August 1 if you can't get it this week. Final thoughts on that?
Yeah, this is where I genuinely buy into McConnell’s strategy. This is already a very unpopular bill, and it’s not going to get any more popular.
I’m not sure time is your friend.
Ha, that part seems pretty straightforward to me. You come back July 10 and hammer out a deal!
The one thing I’ve learned from the past six months is ¯\_(ツ)_/¯
Yes, Dylan is right. The shruggie is the defining health politics analysis of our moment.