The Senate’s fresh attempt to dismantle Obamacare is already running into its first roadblock — the growing list of demands from GOP lawmakers eager to leave their own mark on the legislation.
Just days into the chamber’s health care debate, centrists and self-styled mavericks are testing the party’s razor-thin margin for victory and setting the stage for a series of high-profile negotiations. Those stare downs are likely to shape big parts of the legislation, since GOP leaders can only absorb two defections if Democrats and the chamber’s two independents stand unified in opposition.
Here are the four potential deal-breakers that could sink the GOP’s Obamacare repeal bid by siphoning support from the political center:
Deep cuts to Medicaid
Who opposes it: Rob Portman, Lisa Murkowski, Shelley Moore Capito, John McCain
The House plan to drastically restructure Medicaid was a big winner for budget-obsessed Republicans intent on shrinking the health entitlement, but it’s a pipe dream in the Senate.
The House-passed bill would do more than just roll back Obamacare’s Medicaid expansion. It would cut more than $800 billion over 10 years from a program that covers nearly 1 in 5 poor Americans and cap its federal funding for the first time.
Already, as many as a dozen Senate Republicans have expressed reservations about slashing that much money from the nation’s safety net. Some are also hesitant to sign off on an abrupt end to the Medicaid expansion, especially in states that have benefited significantly from the broader coverage.
“I continue to have concerns that this bill does not do enough to protect Ohio’s Medicaid expansion population,” Sen. Rob Portman (R-Ohio) said after the House passed its repeal bill.
Sens. Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska have also worried publicly about Medicaid’s future, and John McCain told reporters this week the House’s approach wouldn’t work for him. Altogether, 20 Senate Republicans represent states that expanded Medicaid under Obamacare.
Since the GOP can only afford to lose two votes, Republican leaders are under pressure to embrace a more gradual phase-out of the expansion and far shallower cuts — or maybe even no cuts at all to Medicaid funding.
Fewer protections for people with pre-existing conditions
Who opposes it: Bill Cassidy, Susan Collins
The firestorm that put House Republicans on the defensive is already spreading to the Senate, where lawmakers are facing questions about how they’ll take care of America’s sickest patients. The response from outspoken Republicans like Sen. Bill Cassidy (R-La.) has been clear: He won’t vote for a bill that could leave people with pre-existing conditions unable to afford health insurance.
“The worst possible argument that can be made is that coverage is not important,” he said Monday, referencing President Donald Trump’s vow to take care of everyone with a pre-existing condition. “We have to fulfill that contract that President Trump made.”
But keeping that pledge while still tearing down Obamacare could be tricky. The law’s most protective provisions — including requirements that insurers provide minimum benefits and cover everyone who applies — are among the pillars that Republicans have hammered for making coverage too expensive for healthier people. That could put GOP lawmakers in the uncomfortable position of deciding how far to go to protect the nation’s most vulnerable — and how much more sick Americans should have to pay for the privilege.
Defunding Planned Parenthood
Who opposes it: Susan Collins, Lisa Murkowski
One of the GOP’s longest-standing health care goals is also its most straightforward: cut off federal funding to Planned Parenthood over its abortion services.
But accomplishing that has not been easy, thanks in large part to the staunch opposition of Sens. Susan Collins (R-Maine) and Murkowski. The pair played an important role thwarting Republicans leaders’ bid to eliminate the funding as part of last week’s government spending bill, and they’re sure to block a similar attempt in any Obamacare repeal legislation.
“It’s not the only issue in this huge bill, but I certainly think that it’s not fair and it is a mistake to defund Planned Parenthood,” Collins said on ABC’s "This Week."
The GOP could still plow ahead without their support, relying on Vice President Mike Pence to deliver a tie-breaking vote that pushes a repeal bill through the Senate. But that would mean keeping every other Republican senator on board, from moderates like Portman to conservatives like Sen. Rand Paul (R-Ky.).
Paul is already on record fretting that the current bill might not be radical enough, and is a prime candidate to balk if the Senate tries to bend the legislation toward the political center. On the other end of the spectrum, vulnerable centrist Republicans like Dean Heller (R-Nev.) are likely to feel the heat from women’s health supporters to join Collins and Murkowski in standing against Planned Parenthood defunding.
The ‘Age Tax’
Who opposes it: Susan Collins, John Thune
Even before Republicans opened the door to letting insurers go back to discriminating against those with pre-existing conditions, the repeal effort threatened to make losers out of one of the nation’s neediest groups — poor Americans just shy of the Medicare eligibility age. The House legislation sharply reduces the tax credits meant to subsidize coverage for those in the individual market, capping them at $4,000 and awarding them based on age.
That change — combined with another provision allowing insurers to charge older Americans five times more than younger ones — would make premiums surge for people in that age cohort, potentially pricing out the market’s sickest and poorest people.
The Senate isn’t going to let that stand. John Thune (R-S.D.) is already working on beefing up the tax credits for lower-income Americans, and several senators have hinted at awarding subsidies based on financial need instead of age. Collins, meanwhile, has piled another recommendation on top of that, arguing that the tax credits should be adjusted for geographic-based cost variations as well — an approach that mirrors Obamacare’s current subsidy system.
If the credits don’t factor in geography, “that really hurts a state like Maine, where we have an older population living in largely more expensive rural areas,” she said.