Say this for the health-care circus: It has been a master class in how difficult and delicate governing (as opposed to mouthing off) can be. Hill Republicans have had seven years to come up with a workable, palatable alternative to Obamacare. Instead, they have struggled and scrambled and, in shadowy, secret corners of the Capitol, cobbled together a plan—well, a succession of plans—that has thus far proved less popular than Mel Gibson at an Anti-Defamation League convention.
The impressive thing about the GOP plan is not that voters dislike it. (Though a 17 percent approval rating does merit a certain awe.) Nor that Democrats refuse to engage with it. (This is the definition of a political given.) It’s that, despite having drafted the plan along partisan lines, and with the comfort of a president who has made clear he’ll sign whatever mishmash hits his desk, Senate Majority Leader Mitch McConnell is struggling to find 50 of his own members to back the plan. The most recent version, introduced Thursday, lacked the support necessary to even begin debate. On Saturday night, McConnell announced he would postpone any consideration of the bill until after Senator John McCain returns from his surgery.
What is it about the bill that’s such a turn off? Depends on who you ask, when, where, and which version of the plan they’re looking at. (With policy this complicated, there’s typically something for everyone to hate.) And since the plan keeps morphing as leadership cuts some regulations here and adds some money there in the ongoing push to woo specific lawmakers, it can be tough to keep track of who is (or is not) signing on to what. (This is itself a sneaky tool of the trade.)
So, for those keeping score at home, here’s a watercooler-ready cheat-sheet on several (but not all!) of the Senate Republicans who, as of the latest rollout, remained publicly angsty about the bill, along with the particulars they say are bugging them. (As always, a lawmaker’s true, full motivation remains one of the universe’s great mysteries.):
Susan Collins. For the Maine centrist, the provision stripping federal funding from Planned Parenthood for one year has been a sticking point from the get-go. Again this past week, she slammed the effort as “short-sighted” and “unfair” and pledged to keep working to strike the language from the bill.
More broadly, Collins is one of many Republican senators worried about the plan’s deep and steep cuts to Medicaid. After the conference’s Thursday briefing on the revised bill, Collins told reporters she feared the cuts “would shift costs onto state governments, it would hurt the most vulnerable citizens, it would have an adverse impact particularly on our rural healthcare providers, our hospitals, and our nursing homes. And it is not something that I can support.” Having snagged one of the two free-pass “no” votes, Collins is disinclined to let the bill even proceed to the floor for debate.
Rand Paul. The Kentucky Tea Partyer is the only other Republican thus far to Just Say No. (Which means both free passes are taken, leaving the rest of the lawmakers on this list to flounder in various states of “concern.”) Makes sense. The dude’s a libertarian. He loathes everything about Obamacare, with its Big Brothery regulations and mandates and taxes—too many of which, he feels, are preserved, and in some cases expanded, by the GOP plan.
In particular, Paul has zero use for the refundable tax credits to help lower-income folks buy coverage. And no way he’s going to get behind a stabilization fund aimed at helping insurers offset the costs of high-risk enrollees. His office helpfully directed me to an op-ed by Paul that ran in Breitbart on Wednesday, in which the senator trashed his party’s plan as “Obamacare-lite.” (“One might even argue it’s worse,” he wrote, “because it actually creates a giant superfund to bail out the insurance companies—something even the Democrats feared to do.”) His verdict: “Shame.”
Mike Lee. This ultraconservative has been on a bit of a rollercoaster ride. His preference is for total annihilation of Obamacare, and he rejected the original Senate bill outright because it didn’t scrap enough of the ACA’s regulations. But then he huddled up with his buddy Ted Cruz to champion what has come to be known as the Cruz amendment or the Cruz-Lee amendment. This provision would allow insurers to sell policies that did not meet Obamacare’s coverage standards so long as they also offered at least one option that did. After some back-and-forth, leadership dug the proposal enough to put it in the rewrite. And voila! Lee wound up unhappy again.
Wait. What? Turns out, in all the back-and-forthing, Cruz agreed to keep Obamacare’s “single risk pool” rule, which bars insurers from sorting enrollees into different pools based on how high-risk (read: expensive to cover) they are. Lee is so not down with that. The whole point of the amendment as he saw it was to prevent those who cannot/do not want to spend much on insurance from having to subsidize more expensive enrollees. If insurers must keep everyone in the same risk pool, Lee fears, the problem will endure. So neither the basic bill, nor the current Cruz-Lee amendment, are really working for Lee.
Lisa Murkowski. Like Collins, the outspoken Alaskan has made clear she does not appreciate her colleagues’ targeting of Planned Parenthood. It will be fun to see how aggressively she pushes back if debate on the bill ever gets rolling.
Of course, Murkowski is also concerned about what Medicaid rollbacks would do to her Medicaid-dependent state. To alleviate her fears, McConnell has been waving big wads of cash under her nose. The latest bill includes a provision that would funnel serious money to states “where the cost of insurance premiums are at least 75 percent higher than the national average.”
As more than one keen observer has noted, exactly one state falls into this category. Yep. Alaska. (This has cheekily been dubbed the “Polar Payoff.”)
Hundreds of millions in subsidies would definitely take some of the sting out of the Medicaid cuts to which Murkowski has objected. Her office did not respond to my inquiries about her latest leanings. But McConnell has clearly given her much to think about.
Then there’s what we can loosely call the Medicaid fretters, Senators from states that expanded the program under Obamacare and are now soiling themselves at the thought of what will happen if the money gets yanked and a slew of their constituents lose coverage. (Even voters who rail against Big Government tend to get grumpy when you take away their government benefits.) McConnell has reportedly been pushing the foot-draggers to vote “yes” now and worry later. The majority leader has a big pool of money to play with on this issue, and all sorts of promises and side deals are being floated with individual lawmakers.
Rob Portman. The Ohioan is miffed that the Senate bill has even steeper cuts to Medicaid than the House version. He has consistently agitated for a longer transition period for the rollback (a gentler “glide path,” in the hot health-care lingo), and he absolutely wants generous tax credits and/or subsidies for those who lose Medicaid and must find alternative coverage.
Shelley Moore Capito. It’s tough to blame Capito for her Medicaid fixation. More than a quarter of West Virginians rely on the program. One-tenth are insured specifically through the ACA’s Medicaid expansion. McConnell has been tempting Capito with extra millions to battle her state’s opioid crisis. (West Virginia has the nation’s highest rate of drug overdose deaths.) But that has yet to seal the deal.
Bill Cassidy. For months now, the Louisiana physician has been the hardest-working man on the Hill when it comes to pushing alternatives to his party’s plan. In January, he and Collins introduced their own bipartisan proposal. Then on Thursday, right before McConnell rolled out his rewrite, Cassidy and Lindsey Graham popped up with a surprise alternative that would funnel health care money to the states. Hardly a vote of confidence.
Cassidy has said he’s waiting on the CBO score of the rewrite before passing final judgment. Clearly he’s hoping something will save him from it.
John McCain. The saucy maverick hasn’t been as critical of his party’s plan as some—although he has repeatedly voiced his conviction that it will fail. After Thursday’s rollout, McCain issued a statement of disappointment that the rewrite “does not include the measures I have been advocating for on behalf of the people of Arizona.” (Read: less violence to Medicaid.) If it moves forward, McCain vowed, he will fight to amend it.
Dean Heller. It’s one thing to have your state’s Medicaid funding threatened by a wildly unpopular bill. It’s quite another to have that happen while facing a reelection battle in a purple state. Heller, whose term is up next year, flat-out rejected the initial Senate bill. (“I cannot support a piece of legislation that takes away insurance from tens of millions of Americans and hundreds of thousands of Nevadans.”) Since the rewrite, he has been noticeably quieter—and McConnell has been noticeably whispering in his ear. (Heller has said his conversations with leadership have been “very, very good.”) Certainly, it could prove handy to have the majority leader in his debt come reelection time.
John Hoeven. The North Dakota senator firmly opposed the Senate’s first draft. Of his views on the rewrite, his office sent me an exquisitely vague, effectively contentless statement. Hoeven wants all Americans to have “affordable” coverage and “access to patient-centered” care. (Don’t we all?) He is reserving final judgment until he has seen “the CBO score and additional analysis.” Hard to get more noncommittal than that.
Three dissenters. (One, if you count Collins and Paul as lost causes.) That’s all it would take for this whole spectacle to go up in flames. It’s enough to give even the unflappable, lizard-like McConnell a stress headache.