Mitch McConnell has little margin for error as he tries to salvage the Senate’s Obamacare repeal effort over the July 4 break.
The majority leader has to craft a compromise that tears down enough of Obamacare to satisfy the party’s conservative wing, while also ensuring the health benefits are generous enough to keep skeptical moderates in line. He can only lose two of the 52 Republican votes, and use Vice President Mike Pence as a tie-breaker.
Here are the five items on McConnell’s menu:
The Medicaid mess
The Senate health care bill would gut the safety net program, rolling back Obamacare’s expanded coverage and slashing its funding by $772 billion over a decade. And that’s perhaps the main obstacle facing McConnell as he tries to win over a crucial bloc of moderate GOP senators.
Republican leaders may try to soften the blow to Medicaid to win over several holdouts by considering lengthening the phase-out of generous funding for Medicaid expansion and easing the cap on the whole program’s funding. Senate Republicans hailing from expansion states — like vulnerable Nevada Sen. Dean Heller and key swing vote Rob Portman — have pushed for as long as a seven-year phase-down, far longer than the bill’s current three-year track.
McConnell may also float the potential for excluding certain groups from the program’s funding limits, in a bid to maintain coverage for some of the neediest Americans and relieve the financial burden on cash-strapped states.
But changes along those lines would put GOP leaders at risk of losing key conservatives who see Medicaid spending as out of control. Sen. Pat Toomey has led the charge to end the program’s entitlement status, with support from several other senators eager to limit Medicaid’s reach.
“Medicaid was initially set up to help the poor, women, children and the disabled,” Sen. John Barrasso said. “It has been taken in a direction way different than that."
The battle over Obamacare’s subsidies
McConnell is also likely to weigh making the Senate bill’s tax credits more generous to alleviate concerns that poorer and older people wouldn’t get enough aid to purchase insurance on the individual market.
The current bill scales back those subsidies and cuts off eligibility at 350 percent of the federal poverty line, compared with Obamacare’s 400-percent threshold. The restructuring disproportionately benefits younger and healthier enrollees, the Congressional Budget Office projected Monday, raising concerns that older and poorer patients would be forced to pay significantly more for health care, or go without.
But Republican leaders can easily dial those subsidies back up if they are key to winning over swing votes like Sens. Susan Collins or Lisa Murkowski.
“I’m very concerned about the impact on premiums generally, particularly for that very vulnerable group between age 50 and 64,” Collins said.
What may not be so easy: Getting the conservative wing to go along with the bigger tax credits. Sen. Rand Paul — perhaps the most consistent opponent of the bill — has railed against the subsidies as just a perpetuation of Obamacare. Another holdout, Sen. Ron Johnson wants to eliminate that financial aid altogether.
Rolling back Obamacare regulations
Bringing conservatives back into the fold starts with repealing as much of Obamacare as possible — and that means doing more to gut the health law’s regulatory structure.
Paul, Ted Cruz and Mike Lee have pushed to roll back all of the standards governing health insurance plans, including protections barring insurers from discriminating against people with pre-existing conditions. And Republican leaders are already halfway there: The Senate bill lets states waive additional Obamacare rules in a bid to further lower premiums.
“I have been very clear from the beginning how to get my vote,” Cruz said.
But conservatives’ remaining demands are extensive, and include adding provisions — such as medical malpractice reform and allowing insurers to sell across state lines — that could disqualify the bill under the Senate’s strict reconciliation rules.
If he eliminates Obamacare’s protections for sick Americans, McConnell also risks inviting the backlash that nearly doomed the House GOP’s repeal bill. That controversy prompted Sen. Bill Cassidy to declare he wouldn’t support any bill that leaves the sick without access to care. And if moderate GOP senators are already worried about whether the bill maintains coverage for the most vulnerable, further gutting Obamacare’s protections likely won’t get them any closer to “yes.”
The Planned Parenthood problem
The easiest tweak Senate Republicans can make to the bill could also be among its most controversial: stripping out a provision that defunds Planned Parenthood for one year.
Collins and Murkowski — who have long been critical of zeroing out the organization’s funding — are drafting an amendment that would preserve the funds. Incorporating that into the Senate’s revised bill could go a long way toward winning those two crucial moderates. It would also come at little tangible economic cost since it has no effect on the rest of the bill.
But it risks upsetting the vast majority of Republican senators who saw this as their chance to finally cut Planned Parenthood’s funding after multiple failed attempts to do so. McConnell would have to take his colleagues’ temperature before he makes any final decision and weigh whether he can endure the additional backlash from influential anti-abortion groups.
Adding enticements, including more money to combat opioid abuse
McConnell has roughly $188 billion to spend on sweeteners to the health care bill, thanks to CBO’s estimate that it would reduce the deficit by far more than the House-passed version of repeal. That gives him room to dole out aid for senators’ pet issues in hopes of winning their votes, and it could go a long way toward addressing some moderates’ concerns.
Boosting funding to fight the opioid epidemic ravaging many states would likely be a strong inducement for holdouts like Ohio’s Portman and West Virginia’s Shelley Moore Capito.
“This bill will not ensure access to affordable health care in West Virginia, does not do enough to combat the opioid epidemic that is devastating my state, cuts traditional Medicaid too deeply, and harms rural health care providers,” Capito said in a statement laying out her complaints about the legislation.
Republican leaders could also funnel more money into tax credits to reduce the burden of premiums in Alaska’s particularly expensive individual market to lock in Murkowski’s vote, and respond to a range of asks from senators across the spectrum.
Sen. Marco Rubio, for example, said he’s mulling his own set of proposals aimed at shoring up Florida’s Medicaid and individual markets. Of course, sweeteners targeted to specific senators could sow discontent among the rest of the conference, especially those keen on preserving the bill’s deficit savings. That puts further pressure on McConnell to spend his billions wisely.