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The Senate Republican health care bill is daring these moderates to vote for Medicaid cuts

McConnell’s offer is this: nothing.

Alex Wong / Getty Images

In one critical sense, the new Senate health care bill is the same as the old Senate health care bill: It still includes deep cuts to Medicaid.

The revised legislation drafted by Senate Majority Leader Mitch McConnell (R-KY) will make some changes to the original bill, such as adding money to combat the opioid crisis and potentially relaxing Obamacare’s insurance mandates, among other things. But the major revisions are not focused on the government health program that has emerged as a line in the sand for a half-dozen of the more moderate GOP senators.

Those senators now have to decide whether to stand firm on the issue or if other alterations will be enough to win their vote.

It’s a Medicaid Mexican standoff.

Medicaid was always going to be a central issue for Senate Republicans. Twenty of them represent states that expanded the program under Obamacare, covering millions of their poorest citizens. From the start, a critical mass of senators — McConnell can lose only two of his 52 members — said it would be the top issue for them.

The Senate bill as originally drafted would eventually end the generous federal funding for Medicaid expansion in 2024. It would also place a hard federal spending cap on the program for the first time, overhauling it from an open-ended entitlement. The cumulative effect would be 15 million fewer people enrolled in Medicaid and a $772 billion spending cut, versus current law, according to the Congressional Budget Office.

The plan actually includes a lower growth rate for the Medicaid spending caps than even the House bill did, starting in 2025. Several moderate senators have urged Republican leaders to increase the growth rate.

But despite having billions of dollars he could add to the bill, McConnell has decided to keep the deeper cuts. The bill includes some smaller tweaks to the Medicaid provisions, but nothing that seems to address the most pressing moderate concerns.

Senate leadership has been telling senators worried about the Medicaid growth rate change that it could be delayed or canceled before the deeper cuts take effect, according to Republican lobbyists and Senate aides. But McConnell is still asking those senators to take a vote for a harsher spending cap than they said they could support.

The majority leader does have billions of dollars he can still add to the bill before next week’s expected vote, perhaps specifically targeted to these senators. McConnell must also contend with a revolt from conservatives over how much to roll back Obamacare’s insurance regulations.

But right now the fate of the Senate plan to repeal and replace Obamacare rests on Medicaid and whether these senators can reconcile what they’ve said in the past with a bill that still deeply cuts the program.

Sen. Susan Collins (R-ME): “The Medicaid piece really matters to me”

Collins is maybe the most difficult vote for McConnell to win. She is the most moderate Senate Republican and has been outspoken about her problems with the plan from the start.

Maine has not expanded Medicaid under Obamacare, but Collins has nonetheless been focused on the program during the Senate debate. She is reportedly weighing a run for governor next year — which would make her responsible for administering Medicaid — and she has hinted that Maine could expand Medicaid under an alternative model.

On Wednesday, amid widespread reports that the Medicaid cuts would not be softened in the revised Senate bill, Collins made the issue sound like a deal breaker for her.

"The Medicaid piece really matters to me — and what I’m hearing is that's going to be the same, so that would be a big problem for me,” Collins told National Journal’s Alex Rogers.

Sen. Lisa Murkowski (R-AK): “If you are going to eliminate Medicaid expansion ... that's not increasing access”

Alaska has expanded Medicaid under Obamacare, and Murkowski told the state legislature that as long as they wanted to keep the expansion, she would as well.

When I spoke with Murkowski last month, she made it sound like any plan that eventually ended the generous Medicaid expansion funding would be a big problem for her.

“I want greater access and lower costs,” she said. “If you are going to eliminate Medicaid expansion or even if you're going to wind down Medicaid expansion, that's not increasing access.”

Politico reported that Murkowski chastised Senate leadership in a private meeting this week for overhauling Medicaid as part of their Obamacare repeal bill:

In a closed-door meeting of Senate Republican chairmen Wednesday, Lisa Murkowski ripped GOP leaders’ attempt to scale back Medicaid spending in their Obamacare repeal bill.

The two matters were unrelated, she argued, because the Affordable Care Act did not change Medicaid spending levels across the entire program. The independent-minded Alaska senator was backed up by Sen. John Hoeven of North Dakota, a Republican generally aligned with leadership, according to senators and people familiar with the conversations.

“Let’s set Medicaid off to the side,” she told Politico.

Sen. Dean Heller (R-NV): “This is all about Medicaid expansion”

Heller faces the toughest reelection of any Senate Republican in 2018. His state’s popular Republican governor, Brian Sandoval, expanded Medicaid under Obamacare and has been fiercely critical of the Republican plan.

The pair actually held a press conference late last month, in which Sandoval slammed the Republican bill and Heller said he couldn’t vote for it unless his state was satisfied.

“This is all about Medicaid expansion,” the senator said. “It’s going to be very difficult to get me to a yes.”

“I want to make sure that we prop up Medicaid, so that we don’t turn the clock back,” he continued. “We can’t let fall behind the progress we’ve made in Nevada.”

I caught up with Heller earlier this week, and he did say there were specific changes that could win his support, but he refused to say what they were. He said his priority was making sure the 200,000 Nevadans covered by Obamacare were held harmless.

Sen. Shelley Moore Capito (R-WV): “The core for me is the Medicaid provisions”

Capito represents another Medicaid expansion state, and West Virginia is uniquely dependent on the program: One-third of its families are on Medicaid. It has also been devastated by the opioid crisis, which has been part of Capito’s argument for less harsh Medicaid cuts. The program is the single largest payer of mental health and addiction treatment in the United States.

Along with Ohio Sen. Rob Portman, Capito has been pushing for more funding to combat the opioid epidemic, and she’ll get it: $45 billion in the revised bill.

But she told me recently that wouldn’t be enough. She wanted the growth rate for the Medicaid spending caps to be increased as well.

“More opioid funding would be very good, very beneficial, but the core for me is the Medicaid provisions,” Capitol said. “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.”

The additional opioids funding is a potent reminder, though, that McConnell still has billions of dollars — we won’t know for sure how much until the Congressional Budget Office releases its analysis of the revised bill — to buy off the remaining holdouts.

Sen. Rob Portman (R-OH): “I continue to have real concerns about the Medicaid policies in this bill”

Portman and Capito have been tied at the hip throughout the Senate debate over their concerns about the Medicaid provisions and the effect on the opioid crisis.

Ohio expanded Medicaid, and Gov. John Kasich has harshly criticized the Senate plan. The state has also been hit hard by opioid overdose deaths.

Portman and Capito released tandem statements opposing the original Senate bill over the Medicaid cuts.

“I continue to have real concerns about the Medicaid policies in this bill,” Portman said in his statement, “especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic.”

Sen. John Hoeven (R-ND): “I’m obviously in that camp”

Hoeven, who represents yet another Medicaid expansion state, has aligned himself with Portman and Capito on the Medicaid issue over the past few months. He has been less publicly outspoken, but piecing together his comments over the past month or so reveals yet another senator preoccupied with the Medicaid cuts.

“I’m working with Rob. I’m obviously in that camp,” he told Politico in May, adding, “I don’t agree with the House bill,” on the Medicaid provisions.

The Bismarck Tribune reported that Hoeven privately told a group of North Dakota health care executives earlier this month that he “doesn’t support the bill as it stands.”

He also, according to Politico, backed Murkowski in her closed-door criticism of the legislation for its Medicaid overhaul.