With only a slim majority in the Senate, Mitch McConnell always faced an uphill battle uniting the fractious Republican Party behind his plan to repeal and replace the Affordable Care Act. But in the four days since the majority leader revealed the draft text of his clumsily named Better Care Reconciliation Act, the revolt within his own caucus has proved more serious than it first seemed. With 10 senators saying they have reservations or outright oppose the bill, as of Sunday afternoon, it was already looking as if McConnell would need a legislative miracle to fulfill the G.O.P.’s seven-year quest to repeal Obamacare—and that was before the Congressional Budget Office released its report on the impact of the bill, which the federal scorekeeper estimated would increase the ranks of the uninsured by 22 million. One person on McConnell’s staff has reportedly been telling people they have only a 60 percent shot at closing the deal, though the odds may actually be lower. Josh Holmes, who previously served as McConnell’s chief of staff, said passing the bill would be like “a 747 landing on a suburban driveway.”
While McConnell can afford to lose two votes, the holdouts are split ideologically between conservatives and moderates. In the former camp are Senators Rand Paul, Ted Cruz, Mike Lee, and Ron Johnson, who say the legislation doesn’t go far enough in dismantling Barack Obama’s signature legislation. In the latter group are Susan Collins, Dean Heller, Lisa Murkowski, and Cory Gardner—among others—who have voiced concerns about the impact the legislation will have on the uninsured rate and its steep cuts to Medicaid, which begin slower but ultimately go deeper than what was prescribed in the House bill. “This bill would mean a loss of coverage for millions of Americans, and many Nevadans. 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,” Heller said on Friday during a press conference.
On Monday, the C.B.O. confirmed the concerns of Heller and his fellow moderates. While the Senate bill is expected to reduce the federal deficit by $321 billion by 2026, over that same period, tens of millions of Americans are also expected to lose coverage. The budget office estimates that over the next year alone, 15 million more Americans would join the uninsured ranks under the B.C.R.A. than under the current law, and an additional 4 million people would lose employer-sponsored coverage. Over the next decade, that figure would balloon to 22 million—representing a marginal improvement over the House health-care bill. Premiums are also expected to spike by 20 percent in the first year, though the C.B.O. estimates that they will be roughly 30 percent lower in 2026 than under the A.C.A—primarily because plans would be stingier, and deductions much higher. While the highest-income households would benefit from a cumulative tax cut of some $541 billion over the next decade, that’s likely cold comfort to moderates like Collins, Heller, Murkowski and Gardner, who could face an electoral revolt in their home states.
Prior to the release of the C.B.O. score, Collins was already seen as less persuadable than some of her Republican peers. Along with Murkowski, the Maine senator has raised issue with language that would effectively defund Planned Parenthood—the removal of which could be a nonstarter for staunch conservatives like Lee and Cruz. And while Murkowski could be won over by changes to the bill that would help her home state of Alaska, Collins would be a much tougher sell. “She wants to remain engaged in negotiations, so it makes sense not to foreclose the option to vote ‘yes,’ ” the source told Allen. “But there is no way she'll vote for this bill, just on pro-life protections alone.”
Some of the protests are likely less than genuine, designed to extract concessions from McConnell that those senators can then bring back to their states. But other dissenters seem more ideologically opposed to the bill. Paul, Mike Allen notes, seems hung up on conservative principles and is expected to use his opposition to make a stand. He's talking about getting a 60-vote threshold revamp of [Obamacare],” one Senate source told him. “He wants this bill to fail.”
Nor are Collins and Paul the only Republicans who may end up voting “no.” Heller, who is widely seen as the most vulnerable G.O.P. senator in 2018, is the only moderate to have outright opposed the bill as currently written. McConnell, who is famously protective of his caucus, is expected to give Heller a pass, if they can’t negotiate a compromise. A pro-Donald Trump political group, meanwhile, has announced plans to launch a series of attack ads against Heller over health care, leaving the Nevada senator in an even tougher spot, and potentially undermining McConnell. Under attack from Trump’s allies, any concession by Heller now would look as if he folded under pressure—particularly in light of the C.B.O.’s devastating report.
The strict rules governing the budget reconciliation process, which McConnell plans to use to avoid a Democratic filibuster, create a separate set of problems. While Lee is considered amenable to negotiating, the changes he is seeking to the bill might violate the parameters for reconciliation. “I do think [Lee] wants to get to ‘yes.’ I think he realizes that if this fails, it kills the reconciliation vehicle and possibly the chance to repeal major elements of Obamacare,” Allen’s source noted. “But his vote will come [with] major improvements that may or cannot be accommodated by the budget rules constraining [reconciliation].” Lee and the rest of the conservative coalition will, however, likely applaud the $772 billion cut in Medicaid over and the cumulative $541 billion tax cut the Senate bill will provide over the next ten years—whether it will be enough to sway their votes remains to be seen.
McConnell is facing a narrow window to wrangle enough support for the Better Care Reconciliation Act ahead of the vote, which is expected as early as Thursday. And there is still one unknown factor at play: Trump. On Sunday, the president confirmed earlier media reports that he had told Republican senators that he thought the House’s American Health Care Act was “mean.” So far, surrogates for his administration have been insisting that the Senate bill’s massive Medicaid cut would not actually break his campaign promise to protect the program—an obvious deception that other allies have struggled to spin. Who knows what will happen if anyone manages to explain to Trump what the legislation would actually do.
