That the first-term Nevada senator came out against the Senate bill was not a surprise. He is the most vulnerable Republican up for reelection next year, and he hails from a state that expanded Medicaid and cast its electoral votes for Hillary Clinton last fall. What did catch Republicans off-guard, however, was just how critical Heller was when he appeared with Governor Brian Sandoval and ripped the bill to shreds. Echoing Democratic talking points, Heller said the bill would result in millions losing coverage, denounced its ending of Obamacare’s Medicaid expansion, and said it would not lower premiums and Republicans promised. He left the door open to supporting the bill with changes, but he warned: “It’s going to be very difficult to get me to a ‘yes.’” The decision of a pro-Trump super PAC to briefly run ads attacking Heller probably didn’t help.
He hasn’t laid out specific demands, but it’s safe to say that at minimum, GOP leaders would have to soften the bill’s cuts to Medicaid, slow down the phase-out of its expansion, and add language or funding tailored to Nevada’s needs. Heller has aligned himself with Sandoval and suggested he won’t support a bill that the governor doesn’t like, so a state-specific carveout might be in the offing.
Like Paul, Lee is a conservative who is rueful that GOP leaders are not repealing more of Obamacare than they are. But the Utah senator has narrowed his demands significantly, and in a Medium post late last week, he said he would be willing to vote for the Senate bill if it allowed states to opt out of the Obamacare system “free and clear.” Lee pitched the idea as something both Democrats and conservatives could like: Liberal states could choose to experiment with a single-payer system, he said, while red states could pursue a looser, market-oriented approach. However, there’s nothing preventing states from pursuing more liberal or conservative approaches now as long as they adhere to the federal standards under Obamacare. What Lee wants is for states to be free of those standards.
As a broad concept, it’s similar to legislation introduced by Senators Collins and Bill Cassidy of Louisiana. But it also means states could be exempt from any of the core insurance regulations of Obamacare—the requirement that insurance plans cover a range of “essential health benefits” and charge equal rates to people with preexisting conditions. A number of Republican senators have vowed to maintain the protections for preexisting conditions, making Lee’s proposal a tough sell.
Cruz is a former rival of Trump’s and a longtime thorn in McConnell’s side, but he has not emerged as the most conservative stickler in the healthcare debate. The Texan has a longer wish list than Lee, but it’s not clear how many of his demands must be met to secure his vote. Cruz wants a bigger expansion of health savings accounts, medical malpractice reform, and the ability for people to purchase insurance across state lines. These are consensus Republican policies, but McConnell could not include them in the Senate bill because they would not pass muster under the chamber’s strict budget reconciliation rules limiting provisions to matters of taxes and spending.