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WASHINGTON — Senate leaders are just one Republican "no" vote away from seeing their health care bill fail for a second time, and they are counting on provisions already added to the legislation — as well as some new efforts aimed at benefiting individual members — to hold a coalition of 50 votes together.
The GOP senators most likely to defect from the bill are those who wouldn't support the original version for various reasons. Efforts to get them on board began shortly after leadership tabled the bill two weeks ago and even more bartering has been underway since the newest version was unveiled Thursday.
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At least ten senators released statements last month saying they couldn’t support the first version of the Better Care Reconciliation Act, but only Sens. Susan Collins, R-Maine, and Rand Paul, R-Ky., have said they will not support the new bill. The others say they are withholding judgment until they can fully digest the legislation.
But some are already starting to soften their opposition. And discussions are ongoing between leadership and those who didn’t get what they wanted in the revisions, with only a few days of bargaining time left before the bill is expected to be brought to the floor on Tuesday or Wednesday.
A look at the details of the new bill shows why some of that opposition may fall away.
To help secure the support of Alaska senators Lisa Murkowski and Dan Sullivan, whose rural state has a high Medicaid population and exorbitant health care costs, a provision in the revised bill gives additional money to help low income people afford health insurance in states where the population falls below a certain threshold.
Only Alaska meets the requirements contained in the bill, leading Bloomberg news to give it the moniker, "Polar Payoff." In addition, Alaska was given a rare exemption to waive some Affordable Care Act requirements by HHS just days ago.
Sullivan’s spokesman, Mike Anderson, said the senator was “still reviewing (the) latest draft.”
Murkowski’s spokeswoman, Karina Peterson, was supportive of the provision, saying “Murkowski has been working to make sure high-cost states are addressed and have a path forward, which is what this provision clearly does.”
It’s unclear if the waiver and the additional money is enough for Murkowski. She also has remaining concerns about Medicaid and the one-year defunding of Planned Parenthood that is in the bill.
Sen. Marco Rubio, R-Fla., is another member who came out against the first version of the Senate bill, saying in a tweet that the health care bill “must change before I vote ‘yes.’”
But on Thursday, he sounded more inclined to support it, saying that there has been “progress for my state in Florida on the Medicaid side.”
The new bill addressed Rubio’s requirements, leading Democrats to dub it the “Sunshine Sellout.” The bill alters Medicaid payments to be based on the numbers of uninsured in a state instead of the number of those on Medicaid. The provision was important to Florida, a large population state, that didn’t expand Medicaid under Obamacare and didn’t want to be lose out from federal dollars compared to the states that decided to expand.
Rubio also is pleased with the provision that freezes Medicaid funding caps in the instance of an emergency such as Zika or Ebola breakouts.
A provision to help Louisiana was also inserted into the new bill that would enable the state to receive more Medicaid money, basing the new formulas on a later start date that is set for after Louisiana began offering a more generous Medicaid program under Obamacare. Sen. Sen. Bill Cassidy, R-La., was highly critical of the first draft of the bill and has said he needs time to examine it more before he makes a decision on this new version.
But most of the members who opposed the original bill are centrists who have reservations about the cuts to Medicaid. In a rebuke to them, no major changes to Medicaid were offered in the new version which keeps in place the roll back of the Medicaid expansion in 2021. Even deeper cuts are to go into place in 2025 by changing the funding formula. It's unclear what is being done to address the objections of some of those senators.
Sen. Dean Heller, R-Nev., is a critical vote to get. He was the first to come out last round saying he couldn't support the bill. “It’s going to be very difficult to get me to a yes,” Heller said on June 23 during a news conference standing next to Nevada's very popular Republican governor, Brian Sandoval.
Even though nothing that would specifically benefit Nevada changed in the latest version of the bill, Heller didn't outright pan it and said discussions continue. “At this point the conversations that I’ve had with the Leader have been very, very good. I would anticipate I’ll have continued conversations with him throughout the weekend," he said.
Pressure from McConnell and the administration is not only focused on Heller but on Sandoval as well. Heller said Sandoval's position is going to play a key role in his decision. Sandoval has championed the Medicaid expansion in Nevada, telling MSNBC that "people are living happier and healthier lives as a result of the Medicaid expansion."
Vice President Mike Pence is at the National Governors Association meeting in Rhode Island where he’ll meet with Sandoval on the sidelines. Sandoval is also expected to meet with Health and Human Services Secretary Tom Price and Centers for Medicare and Medicaid Administrator Seema Verma on Saturday.
McConnell held a meeting in his office Thursday afternoon with Heller and the handful of other senators who have concerns with Medicaid. None emerged saying that they’d oppose the bill and some sounded slightly more optimistic.
Sen. Rob Portman, R-Ohio, attended the meeting and said that the $45 billion in funding added to the bill for opioid treatment was “progress.” He also said there is an attempt to address his Medicaid concerns.
“We’re still working (on) making some changes that we think will be important to low income individuals in my state,” Portman told reporters.
President Donald Trump made calls to two senators in the past two days regarding health care, but the strategy behind his calls is unknown. He called Sen. Paul who is very much against the bill and will unlikely change his mind, and he called Sen. Ted Cruz, R-Texas, who is very likely to support the measure.