What Does Mitch McConnell Want on Health Care?

The majority leader’s tactical expertise makes his wishes for the American Health Care Act hard to discern.

Yuri Gripas / Reuters

Trump Schmump. On Wednesday, the high-stakes health-care debate will come roaring back to center stage when the Congressional Budget Office releases its scoring of the American Health Care Act that Republicans rammed through the House earlier this month. Barring some modeling miracle, the crunched numbers are unlikely to render the amended AHCA any more popular than the original version that proved too toxic even for a vote. This will crank up the heat on Senate Republicans’ efforts to hammer out an at least marginally more palatable plan.

With so much on the line, Majority Leader Mitch McConnell would really appreciate it if folks would stop fretting about the nature and function of the Senate’s health care working group. Yes, the 13 lawmakers leading the quest for consensus are all Republicans, and all men. But none of that matters, McConnell’s team has repeatedly (and rather testily) insisted, because this is the U.S. Senate, where every member is a king.

“The working group that counts is all 52 of us, and we’re having extensive meetings, as I said a few minutes ago, every day,” the Majority Leader scolded reporters a couple of weeks back, shortly after the group was announced (and got slammed for its lack of ladies). “You need to write about what’s actually happening, and we’re having a discussion about the real issues. Everybody is at the table. Everybody.”

Maybe. But McConnell does seem to have been mighty picky about who got an official seat at that table. And, Mitch being Mitch, you know he didn’t just throw this bunch together at random.

Indeed, as multiple GOP staffers helpfully point out, the working group is stacked with conservatives and with members of leadership. It is decidedly light on moderating voice likely to stir up trouble. (Most notably: Susan Collins and Lisa Murkowski, both of whom oppose the AHCA’s defunding of Planned Parenthood.)

Members who made the cut are, alphabetically, and with noteworthy qualifications:

Lamar Alexander (Chairman of the Health, Education, Labor & Pensions Committee)

John Barrasso (leadership)

John Cornyn (leadership)

Tom Cotton (staunch conservative)

Ted Cruz (staunch conservative)

Mike Enzi (Budget Committee chairman)

Cory Gardner (a relative moderate from purplish Colorado)

Orrin Hatch (Chairman of the Finance Committee)

Mike Lee (staunch conservative)


Rob Portman (relative moderate, especially when it comes to Medicaid funding)

John Thune (leadership)

Pat Toomey (close to McConnell; hails from the swingy state of Pennsylvania; fiscally conservative member of the Finance Committee who has spent much time pondering how to cut Medicaid costs)

In a display of conference inclusiveness, other senators have been invited to drop in on the semiweekly sessions (including Joni Ernst and Shelley Moore Capito). Ron Johnson went so far as to announce that he plans to sit in on all the meetings, effectively serving as a 14th member. The group’s defenders praise it as a tidy “cross section” or “microcosm” of the overall conference.

Even aides whose bosses are in the inner circle, however, acknowledge that its central aim isn’t so much to achieve ideological balance as to minimize drama—both during preliminary negotiations and once the resulting plan hits the floor. McConnell has no intention of letting his chamber descend into House-like chaos. (In addition to being undignified, it could force his members to take risky political stands.) As such, one of his key challenges is to manage hard-liners.

“McConnell learned from Paul Ryan’s mistake. You can’t just cook up something behind close doors and then expect conservatives to salute and vote for it,” said an aide to a conservative Senator. “This committee is all about getting buy-in from conservative senators early on so they have a harder time saying ‘no’ to the final product.”

Indeed, the roots of the group lie in informal discussions that bomb-lobber Ted Cruz was holding with colleagues a few weeks back. Cruz soon discovered that HELP Chairman Alexander was having his own similar conversations. The two jointly approached McConnell about formalizing a coterie of members to serve as a sounding board/negotiating hub.

McConnell gave the 13 meeting space, a dash of structure, and some specific assignments. (For instance, he has charged Portman and Toomey with figuring out The Medicaid Problem—namely, what to do about the 31 states, including several red ones, that expanded their Medicaid rolls using Obamacare funds.) The group meets on Tuesdays and Thursdays, with each gathering tackling a particular topic (Medicaid, Title 1, the tax credit, etc.). Deliberations are to be kept hush-hush, although Cruz is reportedly giving regular updates to the House Freedom Caucus, which was so central to shaping the final House bill.

This is not to suggest that conservatives are really driving this train. GOP staffers point out that the working group also features a large leadership contingent—the better to ensure that discussions do not spiral too far beyond McConnell’s control. “He wants his people in there to make sure he has loyal voices when needed,” said the conservative aide.

Certainly, it’s not as though the working group’s members are huddled up writing a bill. At this stage, the 13 are being likened to a focus group, with everyone venting their spleens and tossing around ideas and trying to see if anyone can agree on anything. (The early reports are not encouraging.)

In the meantime, other GOP senators are conducting their own talks. Collins, who introduced a health care plan along with Republican colleague Bill Cassidy, has started meeting with a dozen or so senators from both sides of the aisle to see, as she has put it, “if there is a bipartisan path forward.”

And when it finally comes time to hammer out a bill late this summer, rest assured that all working group members will not be created equal. Look for the actual crafting of legislation—whether from scratch or as an amendment overhauling the House plan—to be handled largely by leadership, Alexander, and Enzi.

(Enzi’s budget team is responsible for packaging the plan to meet the requirements of reconciliation so it can pass with a simple majority of 51 votes. For process nerds hungry for details of how that might play out, the budget folks recommend revisiting how the 2015 Obamacare repeal bill was handled.

Indeed, despite hard-liners’ heavy presence on the working group, it’s hard to say how much impact they’ll wind up having on the final bill. Some anxious conservatives even suspect that their overrepresentation on the front end of this process is all part of leadership’s plan to shaft them on the tail end.

“This is classic McConnell,” said the conservative aide. “He loves to invite members to a meeting, float an idea, and then if you don’t object immediately, he will hold that against you as support for the idea.”

No question, McConnell is a master at herding the cats. But the health care drama promises to tax even his formidable gifts. Pretty much every corner of the conference seems twitchy about where the process is headed. No one seems inclined to take a backseat on an issue this major. And, for all the buzz it prompted, McConnell’s little working group could easily wind up being vastly more show that substance—which may well be precisely as the majority leader intended.