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The risky — but not impossible — path forward for the Senate health care bill

“I know McConnell hates losing.”

The Washington Post / Getty Images
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.

The divisions between Senate Republicans about how to repeal and replace Obamacare only seem to be widening, and yet Mitch McConnell must see some path to consensus to fulfill his party’s seven-year pledge to undo the health care law.

"We're not going to vote this week, so we have more time to work on it until we get it done,” Sen. John Cornyn (R-TX), McConnell’s top lieutenant, said Tuesday.

That is the one certainty from the Senate majority leader’s decision to postpone a procedural vote this week on his health care plan, a vote that seemed doomed to fail after five conservative and moderate senators came out against it. McConnell could have held the vote, let it fail, and decided to let the Obamacare repeal dream die. But he instead elected to take the time, and the risk, of pushing forward.

So the bill isn’t dead yet. McConnell has some leverage to work with: The draft legislation provides nearly $200 billion that he could add to the bill while still meeting the savings targets he must under the Senate’s “budget reconciliation” rules, and he’ll undoubtedly pressure Republicans to deliver on the promise to repeal Obamacare.

Nobody in Washington seems sure what compromise Republican leadership could cook up to win over their most anti-Obamacare senator, Rand Paul of Kentucky, and their most moderate member, Susan Collins of Maine. McConnell can lose only two of the 52 Senate Republicans and still pass the bill — an overwhelmingly unpopular plan currently projected to leave 22 million fewer Americans with health insurance by 2026 and cut Medicaid by $772 billion over 10 years versus current law.

McConnell is essentially getting pulled in two opposite directions: The conservatives are pushing to unwind as much of Obamacare’s insurance regulations as they can, and the moderates want more federal spending, particularly on Medicaid, and to preserve some of Obamacare’s core policies. He’ll need some holdouts from both sides to come around if he’s going to get 50 votes.

It seems like an impossible task. Indeed, when I asked what the majority leader’s strategy might be, one Republican health care lobbyist said: “Throwing $188 billion of spaghetti at the wall?”

McConnell needs to cut big deals now, and his options are limited

Senate leaders are aiming for a speedy turnaround on a health care compromise: McConnell wants to have a new bill by the end of the week, so they can send it to the Congressional Budget Office next week, Axios reported.

He’ll have to make quick work of it. Several critical swing votes said this week that they’ve yet to receive personal calls from Republican leadership since the health care bill was released last week. McConnell had been holding closed-door negotiations over the past month, but senators had less than a week to review the actual legislative text before he planned to bring the bill to the floor for a vote.

"So far, I've had not one call from Senate leadership," Paul told reporters Monday. "I've gotten a call from the White House, but nobody from Senate Republican leadership is interested at this time in our vote."

Even essential votes inside Republican leadership have bristled at McConnell’s lack of leeway thus far. West Virginia Sen. Shelley Moore Capito, a member of the GOP whip team, has been saying for weeks that she was concerned about the emerging plan’s Medicaid cuts and funding for the opioid crisis killing 30,000 Americans annually.

Yet she told reporters Tuesday that she’d seen no flexibility from leadership thus far.

"There are several things that we've put on the table," Capito said. "At this point, there’s not much give."

McConnell can buy off votes with the nearly $200 billion he has left in the bill, and he is also certain to lean heavily on the argument that Republicans promised for years that they would repeal Obamacare.

The bill, as is, makes nobody happy. It cuts Medicaid deeply and scales back Obamacare’s financial aid for people who buy private coverage. It’s projected to reduce premiums in the long term, but only because people would see higher out-of-pocket costs. But then it also keeps some of the health care law’s major insurance regulations, a cardinal sin for conservatives.

The bottom line is that CBO estimates 22 million fewer Americans would have health insurance under the plan 10 years from now.

“His problem is that the policy is just really bad,” another Republican health care lobbyist told me. “What I feel pretty strongly about is that nibbling around the edges won’t get him what he needs. Nibbling doesn’t change the CBO score narrative.”

He must get hardline conservatives on board, who are gunning for Obamacare’s insurance regulations

In recent days, conservative senators have gotten bolder in demanding that the Senate’s bill roll back more of the health care law’s insurance regulations, up to and including the requirement that health plans cover every American, no matter their health. Right now, the Senate bill allows health plans to charge older people higher premiums and gives states more flexibility to waive those regulations, but otherwise keeps most of Obamacare’s insurance reforms in place.

They think unwinding those rules would lower premiums, while they point to high-risk pools as a way to cover people with high medical costs. Expert analyses of the House bill, which leaned heavily on those pools, thought the plan did not provide nearly enough funding to adequately cover the sickest Americans.

These senators have a lot of leverage. Right now, a quartet of conservatives — Paul, Mike Lee of Utah, Ted Cruz of Texas, and Ron Johnson of Wisconsin — say they oppose the current plan. That’s enough to block it. Politico reported that leadership could give them some fig leaves on health savings accounts, a conservative favorite. But right now, the most anti-Obamacare senators have their sights set much higher.

“I would recommend people go back to what were the conditions prior to Obamacare, embrace those conditions, embrace free markets,” Johnson told me. “Get rid of the mandates that have artificially driven up the costs of insurance. We can do this ... and solve the problem of preexisting conditions using high-risk models."

Such a plan has two big problems, if McConnell wanted to pursue it. First, it could alienate the moderates; Collins told me weeks ago that she wanted to protect people with preexisting conditions. Other important votes like Bill Cassidy of Louisiana have been outspoken about keeping President Trump’s promise to protect those Americans.

Second, those changes might violate the Senate’s procedural rules, which are supposed to limit the bill to policies that directly affect federal spending and revenue. Many outside experts are skeptical that changing insurance regulations could be considered to have a direct effect on the federal budget.

The conservatives are fighting back, though, arguing that the bill already loosens Obamacare’s rule for how much of a person’s medical costs health plans must cover. They think McConnell can push it further and persuade the Senate parliamentarian that these provisions comply with the Senate’s “Byrd Rule.”

“If one of those market reforms, because it relates to premiums, which relates to subsidies, has a budgetary effect; if one of the smaller market reforms ... can survive the parliamentarian ruling, why couldn’t one of the larger ones?” Johnson told me.

Their ultimate “nuclear option” would be to disregard the parliamentarian and have Vice President Mike Pence decide what policies should be allowed in the bill. But senior senators have so far opposed that course of action, advocated by Cruz.

McConnell also needs some moderates, who want more money for Medicaid and opioids

On the other end of the ideological spectrum, more moderate senators have been saying for weeks that they want to soften the Medicaid cuts and want additional funding for the opioid crisis.

In its current form, the Senate bill gradually ends the general federal funding for Obamacare’s Medicaid expansion, which covered millions of poor Americans, in 2024. It also places a federal spending cap on the entire program for the first time. The result, according to the CBO, would be a $772 billion cut, versus current law, and 15 million fewer people enrolled in Medicaid a decade from now than under Obamacare.

Twenty Republican senators represent states that expanded Medicaid under Obamacare, and several — including Capito and Rob Portman of Ohio — have made the program their top issue. Some of those senators, like Dean Heller of Nevada and Lisa Murkowski of Alaska, seem uncomfortable with ending the Medicaid expansion at all.

“I want greater access and lower costs. So far, I'm not seeing that happen,” Murkowski told me earlier this month. “If you are going to eliminate Medicaid expansion or even if you're going to wind down Medicaid expansion, that's not increasing access.”

But even others like Capito, who seem willing to work within McConnell’s current plan of eventually ending the expansion and capping Medicaid spending, aren’t satisfied with the current bill. They also want more money for the opioid crisis — Medicaid is the single largest payer of addiction treatment in the nation.

The Senate bill right now includes only $2 billion in one year for the opioid crisis; Portman and Capito had been asking for $45 billion over 10 years, an estimate based on the projected cuts to Medicaid. That seemed like one obvious area where McConnell could use his spare $200 billion to win over skeptical senators.

But the math is an uphill battle here. The opioid funding would be directed to state programs, but Capito said that money might not help much if people with addiction issues lost coverage because of the Medicaid cuts.

“More opioid funding would be very good, very beneficial, but the core for me is the Medicaid provisions,” she told me Tuesday. “You can grant the state more money for treatment, but if you can’t access the treatment, it’s not going to do you any good.”

Yet here, again, any concessions McConnell makes to moderates could risk alienating conservatives. The right wing fought hard to reduce the Medicaid spending caps in later years even more than the House bill did. They might balk if McConnell attempts to scale back the current bill’s cuts to appease the moderates.

“I support the Senate bill,” Sen. Pat Toomey, who fought for the steeper Medicaid spending caps, told me Wednesday when I asked about changing that piece of the plan.

That’s the central riddle for the majority leader — how does he thread the needle when his conference’s demands seem diametrically opposed? Right now, nobody can see the path forward.

“The tweaks that they are seeking aren’t enough as far as I can tell at the moment,” a third Republican lobbyist told me. “But I know McConnell hates losing.”

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