WASHINGTON — Senate Majority Leader Mitch McConnell's effort to pass the GOP health care plan got a little harder Friday when Nevada's Dean Heller became the fifth Republican senator to say he can't support the bill in its current form.
McConnell intends to put his health care bill up for a full Senate vote next week but he's facing increasing pressure from both ideological wings of his party to find the 50 votes he needs to pass the bill.
"This bill that’s currently in front of the United States Senate ... is simply not the answer, and I’m announcing today that in this form I will not support it," Heller said at a news conference in Las Vegas with Gov. Brian Sandoval Friday morning, pointing to the bill's dramatic reductions in Medicaid.
"I'm telling you right now, I cannot support a piece of legislation that takes insurance away from tens of millions of Americans and hundreds of thousands of Nevadans," he said.
Heller is the only Republican senator up for re-election in 2018 in a state that Trump lost, making him one of the most vulnerable Republicans in the next election. More than 600,000 people in Nevada are on Medicaid, including disabled and low-income children.
Heller also undercut Republican arguments in favor of the bill. He called it a "lie" that the GOP plan would help people's insurance premiums to go down.
"If this bill passes, the second biggest lie is your premiums are going down. And there isn't anything in this piece of legislation that will lower your premiums," Heller said.
A day after the legislative draft was unveiled, it remained far from clear that McConnell will be able to assemble the votes to pass a measure that was largely crafted during weeks of closed-door meetings.
Heller joined four conservative senators who came out against the bill Thursday, albeit for far different reasons, including that the Medicaid cuts aren't large enough, proving that McConnell's path to 50 is complicated.
McConnell has a dilemma similar to the one House leaders faced in passing their health care bill last month: If changes are made to accommodate moderates, they’ll surely lose the support of conservatives. And if they alter the bill to appeal to conservatives, the moderates could bail.
The House was able to strike enough of a balance to get it passed — by just one vote. And Republicans have a narrower margin in the Senate, needing at least 50 of the 52 GOP members to pass their bill.
Still, McConnell is expected to hold a vote regardless of whether there is enough support to pass it.
A major tool McConnell has is to offer each member what they want and strike that delicate balance of give-and-take. Democrats used that approach to pass the Affordable Care Act in 2009. In their search for 60 votes then, Senate Democrats agreed to pay 100 percent of Nebraska’s Medicaid costs to convince moderate Democrat Sen. Ben Nelson to support the bill. It was aptly named the Cornhusker Kickback.
Four conservative senators already placed their stake in the sand just hours after the text of the legislation was released. Sens. Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah and Ron Johnson of Wisconsin immediately came out and said they couldn’t support the bill in its current form. Four senators speaking in bloc gives them more negotiating power if their group is larger than the moderates who might vote no.
“I think the choices are do they want our votes or don’t they not want our votes. They have to have at least two of the four of us and so that means that the bill has to get better and it has to get more to our liking,” Sen. Paul said on NBC News’ “Today.”
By meeting conservatives’ demands, moderates could move further away, which would also put at risk the bill’s passage.
Sens. Susan Collins of Maine, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia and Rob Portman of Ohio have all said that they have concerns. Heller and Jeff Flake of Arizona could have difficult re-election races in 2018, so their vote could impact if they return to Washington for another term.
“It isn’t any one factor but it’s all of those factors put together that will influence my decision,” Sen. Collins said on “MTP Daily” of a list of her concerns.
Here are the big issues in play and where the divisions are:
Medicaid coverage is a huge issue for moderates and senators from expansion states. They are concerned with deep cuts to Medicaid in the Senate bill that are set to begin in 2021 by ending the Obamacare Medicaid expansion and be greater in 2025 by changing the formula to adjust benefits coverage according to the rise of inflation instead of the rise of medical costs, which rise more quickly.
Conservatives meanwhile say that Medicaid expansion is drawn down too slowly and that states don’t have enough flexibility to implement a state-run Medicaid program. They’d prefer a block grant or a fixed pot of money for states to cover the lowest income residents in a way they see fit.
Planned Parenthood and Abortion
Moderates such as Collins and Murkowski have deep concerns about the bill because it defunds Planned Parenthood. Murkowski said that Planned Parenthood is a critical source of health care for women in her rural state.
But defunding Planned Parenthood is a gift to the Republican base for many anti-abortion senators from red states.
What could decide the issue is that Senate rules might determine that defunding Planned Parenthood won’t pass the guidelines set by reconciliation, a rarely used method the Senate is using to vote on the health care bill because it only requires 51 votes for passage instead of the usual 60.
Sen. Paul said that in some cases, the GOP health plan’s tax credits are “more generous” than Obamacare’s.
The Senate bill gives tax credits to people in the individual insurance market up making up to 350 percent of poverty, compared to Obamacare which subsidizes people who earn up to 400 percent of poverty. So even though will cover fewer people, it provides too much government assistance for small-government conservatives.
Moderates, meanwhile, say that the formula the Senate health care bill is using for tax credits penalizes older, lower-income Americans.