The fate of Republican legislation to repeal and replace major parts of ObamaCare rests on a handful of senators who have strong reservations about the bill and a variety of political reasons to either support or oppose it.
Two Republicans have already said they will vote against a motion to proceed to the bill next week, giving Senate Majority Leader Mitch McConnell (R-Ky.) no margin for error.
If one more GOP senator defects, the bill will fail and party leaders will have to go back to the drawing board or altogether shelve the healthcare reform effort
The Congressional Budget Office score of the bill, expected on Monday, could tip the balance one way or the other — as could pressure from President Trump, their home-state governors, doctors and hospitals.
Sen. Dean Heller (R-Nev.)
Heller has the most on the line as the most vulnerable Republican senator up for re-election in 2018.
A survey last month of 500 registered voters in Nevada by a GOP polling firm found that a majority of Nevadans opposed the House-passed healthcare bill, which the Senate legislation is largely based on. The poll found that only a third of Nevada Republicans supported the House legislation.
Meanwhile, Republican Governor Brian Sandoval, the most popular politician in the state with a 64 percent approval rating has come out strongly against the Senate measure.
Heller appeared with Sandoval at a press conference last month to announce his opposition to the bill McConnell unveiled on June 22, telling reporters “it’s going to be very difficult to get me to a ‘yes.’”
Sandoval said Thursday that he is “greatly concerned for the 204,000” Nevadans who received health coverage under ObamaCare’s Medicaid expansion.
He also said the revised bill unveiled earlier that day “isn’t that much different from its previous iteration.”
Voting for the bill could be a major liability for Heller.
On the other hand, if he sinks it, he could still pay a price at the polls as Trump has warned Wednesday he will be “very angry” if the Senate does not pass the healthcare bill.
Running against Trump did not work for GOP candidates in Nevada last year, even though Hillary Clinton carried the state. Former Rep. Joe Heck (R-Nev.) and former Rep. Crescent Hardy (R-Nev.), who both disavowed Trump, lost races for Senate and House seats, respectively.
Sen. Lisa Murkowski (R-Alaska)
An underrated element in Murkowski’s decision making is her past relationship with McConnell and the broader Republican Party.
McConnell kicked Murkowski off his leadership team in 2010 after she lost Alaska’s Republican primary to conservative candidate Joe Miller.
McConnell at the time urged Murkowski to accept the result of the primary and “move on.” He also made a $5,000 donation to Miller’s campaign.
Murkowski nevertheless won the general election as a write-in candidate by relying on independent and cross-over Democratic votes.
The Senate healthcare bill is particularly unpopular with independents and Democrats and its reductions in healthcare subsidies and Medicaid would hit Alaska’s rural population and expensive insurance markets especially hard.
The Center for Budget and Policy Priorities, a liberal-leaning think tank, concluded this month that the first version of the Senate healthcare bill would reduce tax credits more deeply for Alaskans than people in any other state.
The revised version unveiled Thursday includes a new provision that could allocate more than $1 billion over the next decade to Alaska to reduce the cost of insurance premiums.
Murkowski applauded the inclusion of the language Thursday but declined to say whether she would vote to advance the bill next week.
She has criticized the legislation for setting a lower formula for indexing Medicaid for inflation starting in 2025, arguing it has gone beyond the stated mission of repealing and replacing parts of ObamaCare.
“Let’s leave Medicaid off the table for right now. Let’s bifurcate this,” she told reporters Wednesday. “This is not something that in my view is best done in a reconciliation process.”
Moderate Rep. Susan Collins (R-Maine), who has pledged to oppose the motion to proceed to the bill, made a similar argument against changing funding for traditional Medicaid beneficiaries, noting that ObamaCare “did not rewrite the entitlement program.”
Sen. Mike Lee (R-Utah)
Lee partnered with Sen. Ted Cruz (R-Texas) in pushing an amendment to allow insurance companies to sell any health plans of their choosing as long as they offer at least one that meets ObamaCare’s regulatory requirements.
Cruz announced Thursday he would support the Senate bill after negotiating a side deal with the leadership to amend the Cruz-Lee Consumer Freedom option — but he left Lee out of the talks.
Lee tweeted Thursday morning that the language added to the bill was “based” on the Cruz-Lee amendment but is not the same thing and is so far undecided on how to vote.
It will be tougher for Lee to vote to block the legislation now that two of his fellow conservatives, Cruz and Sen. Ron Johnson (R-Wis.), have flipped from opposing the legislation to now supporting a motion to begin debate.
Cruz agreed to modify the amendment by fusing the risk pools of people who buy cheaper plans subject to less federal regulation and those who purchase costlier federally qualified plans.
Lee has held firmly to the position that the costs of plans for people with pre-existing conditions should not be kept low, something that requires healthy people to bear more financial burden. In private meetings he explicitly objected to ObamaCare’s so-called community rating requirement, which keeps plans affordable to people with pre-existing conditions.
Whether he buys into the compromise Cruz struck with leaders could depend on what the CBO says of its impact on premiums.
Some lawmakers raised questions on Thursday about whether the CBO would provide an analysis for the Cruz amendment before the vote on the motion to proceed. Sen. Bill Cassidy (R-La.), however, who has been active in the internal talks, said he was assured that senators would get a CBO score on the Cruz provision before the vote.
Shelley Moore Capito (R-W.Va.)
Capito’s home state has a lot riding on the proposed Medicaid reforms.
Twenty-nine percent of West Virginia’s population is on Medicaid, making it the state with the highest share of its population relying on the program, according to the Kaiser Family Foundation.
More than a third of the state’s total enrollees, 180,500 adults out of 564,000 people, signed up under ObamaCare’s expanded enrollment.
A poll conducted for the American Medical Association last month found that only 19 percent of 400 West Virginia voters surveyed approved of the House-passed healthcare bill while 42 percent disapproved.
The Senate bill adopts a less generous formula for indexing Medicaid to inflation starting in 2025 by pegging it to inflation for urban consumers instead of medical inflation, which grows at a faster rate.
Capito told reporters Thursday that the CBO score will factor heavily in her decision.
Capito has a closer relationship with McConnell than some of the other GOP holdouts. She serves on his leadership team as counsel.
Sen. Rob Portman (R-Ohio)
Portman has historically had a close relationship with McConnell but things are getting tense between the two men because of the healthcare debate.
McConnell and Portman clashed at a leadership meeting last month when McConnell pointedly reminded his colleague that he supported entitlement reform when serving as budget director for former President George W. Bush.
Portman easily won re-election last year in a swing state that was expected to be closely contested but that Trump carried by 8 points.
But Portman is feeling pressure from Ohio Gov. John Kasich (R), who came out against the Senate bill Friday, calling it “unacceptable” and its Medicaid cuts “too deep.”
Portman, however, is not as closely aligned with Kasich as Heller is with Sandoval in Nevada.
From early on in the negotiations, Senate Republicans suspected Kasich was trying to blow up the negotiations because of his own political aims.
Nearly 700,000 people gained healthcare coverage in Ohio under Obama’s Medicaid expansion.
Portman has long argued for a longer glide path for phasing out generous federal funding for expanded enrollment and expressed concerns about the less generous inflation rate.
He was given a big concession in the revised bill when McConnell included an $45 billion in the revised bill to cover people addicted to opioids, an epidemic in Ohio.