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Are Moderate Republicans Really Willing To Kill A Senate Health Care Bill?

Are the more centrist Republican senators who have expressed doubts about the party’s efforts to repeal Obamacare really serious about voting against it?

There’s reason for doubt. When the bill was in the House, more moderate Republicans eventually folded, allowing the conservatives to get what they wanted. When the original American Health Care Act failed in March (it was not put to a vote because the GOP’s internal counts showed it would have been rejected), there was a bloc of more moderate GOP members who opposed it as being too stingy in terms of covering people and lowering costs for the elderly and poor. The original bill also faced opposition from the conservative House Freedom Caucus, which felt the legislation did not go far enough in repealing Obamacare. It seemed like House Speaker Paul Ryan was in a Catch-22: Any changes to the bill that would appeal to the Freedom Caucus would cause additional defections among the more moderate members.

But that didn’t happen. The AHCA was pushed to the right, with an amendment that allowed states to opt out of certain parts of Obamacare, and Freedom Caucus members overwhelmingly backed the new version of the bill. But moderate Republicans didn’t abandon the bill en masse. Instead, they declared themselves satisfied with the legislation’s inclusion of some additional funding for high-risk pools. They didn’t demand that the House, before voting, wait for the Congressional Budget Office to review the new provisions, even as experts correctly predicted that the CBO, when given time to complete an analysis, would conclude that the changes to the bill would not be that helpful to those with pre-existing conditions or low-income elderly people.

In the end, more moderate House Republicans helped block a bill that, compared to the levels expected under Obamacare, would leave 24 million more people uninsured and helped advance a bill that would leave 23 million more people uninsured.

This recent history is important, because right now Senate Republicans are facing a similar divide to the one that split the House. Six Republican senators, including five from the 31 states that have expanded Medicaid, have been suggesting for months that the Republican health care proposals are too conservative, either in terms of rolling back Medicaid or in not providing enough financial support for people who have pre-existing conditions or those who are elderly or poor. This group includes West Virginia’s Shelley Moore Capito, Louisiana’s Bill Cassidy, Maine’s Susan Collins, Nevada’s Dean Heller, Alaska’s Lisa Murkowski and Ohio’s Rob Portman.

Since the legislation is likely to meet uniform opposition from Senate Democrats, it will need “yes” votes from at least 50 of the Senate’s 52 Republicans, meaning that any three members of this group could kill it.

SENATOR STATE STATE TRUMP MARGIN STATE EXPANDED MEDICAID
Shelley Moore Capito West Virginia +42
Bill Cassidy Louisiana +20
Susan Collins Maine -3
Dean Heller Nevada -2
Lisa Murkowski Alaska +15
Rob Portman Ohio +8
Senate Republicans who could stop the Obamacare repeal

Sources: Kaiser Family Foundation, The New York Times

A competing group of senators is led by Texas’s Ted Cruz and Utah’s Mike Lee, who want the bill to come as close as possible to repealing all of Obamacare. They are the Senate’s equivalent of the Freedom Caucus.

So how might Senate Majority Leader Mitch McConnell square that circle? Perhaps the same way Ryan did. McConnell created a 13-member group to write the health care legislation. This group has been sharply criticized because it does not include any women — McConnell bypassed all five female GOP senators when creating it. Sexism, or a simple lack of consideration for equal representation, is always a plausible explanation for a shortage of female involvement in any Washington process, as women remain underrepresented in key lawmaking posts. But the initial exclusion of women from this group (McConnell now says the group is open to any of the GOP’s 52 senators) may also be about ideology. McConnell included both Cruz and Lee in the group but not Capito, Collins or Murkowski. That suggests (and some conservatives in Washington believe this is the case) that the Senate is taking the same approach toward trying to pass the health care bill that the House eventually did: Get conservatives on board and then dare more moderate members to block it.

There are a few reasons this could work. First, any Senate Republican, no matter how popular, must worry about becoming the key vote that stops the repeal of Obamacare, which is the kind of move that could draw a challenger in a GOP primary for his or her seat. Secondly, with states increasingly voting for the same party for both the U.S. Senate and president, all but three of the 52 GOP senators (Collins, Colorado’s Cory Gardner, Heller) come from states where President Trump won in 2016. In West Virginia, for example, the number of uninsured residents has dropped dramatically since the passage of Obamacare, in large part because the state chose take advantage of the bill’s provision allowing it to expand access to Medicaid. At the same time, Trump won the state by 42 percentage points in November. Given the level of support the president won in Capito’s home state, can the senator really block a Trump-backed health care proposal?

You might expect that senators’ votes will depend heavily on what is in the final version of the Senate’s health care proposal, which has not yet been fully written. But remember, the House intentionally voted on its health care legislation before the CBO could determine whether the bill would save as much money or insure as many people as legislators were promising. Ultimately, senators may also decide that the details don’t matter that much to them.

So as the Obamacare repeal process gets going in the Senate, those interested in the outcome should watch what more moderate members in the Senate actually do beyond issuing general statements of concern. Do they demand certain changes to the bill and promise to oppose the legislation otherwise? Do they ask the CBO to examine those changes and delay a vote until that analysis is complete? And if a bill that doesn’t meet their goals goes to the floor, will more moderate Republicans actually vote against it?

Liberals are increasingly optimistic about blocking the push to repeal Obamacare in the Senate. But remember, House Minority Leader Nancy Pelosi was literally jumping for joy about the initial failure of the Obamacare repeal in the House, only for the bill to be passed in that chamber about six weeks later.

Perry Bacon Jr. is a senior writer for FiveThirtyEight.

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