The House managed to narrowly pass its ObamaCare repeal bill by finding a delicate balance between hard-line conservatives and moderates. Now the Senate is looking to achieve the same feat, only with a smaller margin for error.
Senate moderates have already put their markers down on the healthcare issues that concern them the most. Individual senators hold much more power in advancing the health bill than individual House members, and if Senate Republicans can’t find a balance among their caucus, the ObamaCare repeal effort could be doomed.
The Senate will only need 51 votes to pass the bill, but because of their slim majority, Republicans can only afford to lose two votes.
The centrist senators have several major concerns with the House bill, known as the American Health Care Act (AHCA), most notably its changes to Medicaid.
The Affordable Care Act allows states to expand Medicaid coverage to more people, funded mostly by the federal government. So far, 31 states and D.C. have done so.
Even as the healthcare bill was working its way through the House, moderate GOP senators hailing from states that took the Medicaid expansion objected to the proposed cuts to the program.
In early March, Republican Sens. Rob Portman (Ohio), Shelly Moore Capito (W.Va.) Cory Gardner (Colo.) and Lisa Murkowski (R-Alaska) sent a letter to Majority Leader Mitch McConnell (R-Ky.) objecting to the Medicaid cuts in the House bill. “We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” the lawmakers wrote.
The legislation has changed since then, but the Medicaid provisions have been largely left alone. The House bill would undo ObamaCare’s Medicaid expansion by 2020, and would cut over $800 billion from the program.
After the House passed the legislation last week, Portman, Capito and Sen. Dean Heller (R-Nev.) were quick to say they still opposed the bill because of the Medicaid provisions.
Capito on Monday said she would like to see some form of Medicaid expansion remain permanent.
“I have seen a lot benefits to the Medicaid expansion in our state, particularly in the mental health and opioid and drug abuse areas,” Capito told reporters. As for the people who have gained coverage through expansion, Capito said “you can’t just drop them off and wish them good luck. “
Moderates have also objected to the fact that the most recent estimates of an earlier version of the House bill would have resulted in 24 million fewer people having insurance coverage over a decade.
Sen. Bill Cassidy (R-La.) has crafted, along with Collins, a different ObamaCare replacement bill that would allow states to decide whether they want to keep ObamaCare or enact something different.
Cassidy has repeatedly objected to the House version of the legislation because he says it doesn’t fulfill President Trump’s promises to “lower premiums, maintain coverage and protect those with pre-existing conditions.” During a May 8 speech at the American Hospital Association, Cassidy said that while the AHCA may lower premiums, it does so by giving people “terrible coverage.”
Aside from coverage issues, abortion is also likely to cause some headaches in the Senate.
The primary group in the Senate working on the bill includes prominent conservatives like Ted Cruz (R-Texas) and Mike Lee (R-Utah), who are likely to insist that the Senate keep a provision from the House that largely strips Planned Parenthood of funding. But Collins has said any Planned Parenthood language is a non-starter.
Moderates are also likely to insist on making sure language is removed from the House bill that would prohibit the bill’s tax credits from being used to purchase coverage on insurance plans that cover abortion. That could be a major problem for conservatives, especially if the revised bill is to have any chance at passing the House again.
Senate Majority Whip John Cornyn (R-Texas) on Monday acknowledged the balancing act leaders will need to pull off. “Now it’s a question of building consensus within the Republican conference. All 52 Republican senators are going to be part of the process … because we’re going to need everybody.”
Cornyn also said he wasn’t concerned about losing votes if the Planned Parenthood language remained in the bill.