Everyone should have seen the Graham-Cassidy Obamacare repeal bill coming. But we didn’t.
Democrats had spent months defending the Affordable Care Act — and they appeared to have succeeded. So just over a week ago, a group of liberal members of the U.S. Senate rolled out their proposal to create a Medicare-for-all program. The group, led by Bernie Sanders, didn’t directly say, “We saved Obamacare, so now it’s time to move on to something even more liberal,” but that was the gist.
How did Democrats end up getting caught so flat-footed, putting out a single-payer proposal that essentially has no chance of becoming law until the White House changes hands while an effort to repeal one of the party’s signature achievements of the last decade gained strength? Because aside from Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina, basically everyone in Washington — Republicans, Democrats, the media — assumed the Obamacare repeal effort was dead. Two weeks ago, President Trump was suggesting that Republicans needed to give up on Obamacare repeal and focus on tax reform, Sen. Lamar Alexander of Tennessee was writing a bipartisan bill to fix Obamacare and Senate Republican leaders were downplaying the possibility that the Obamacare repeal effort would be revived.
So what happened?
Most importantly: Dean Heller of Nevada moved from a weak no to a firm yes — but no one really noticed.
The rise of Graham-Cassidy began on the afternoon of July 27 — hours before the Obamacare repeal effort seemed to die in the Senate. (GOP Sens. Susan Collins, John McCain and Lisa Murkowski formally voted down the “skinny” repeal after 1 a.m. on July 28.)
On that summer Thursday, Heller — who had been one of the Republican holdouts on a bunch of other Obamacare repeal proposals, arguing they cut Medicaid too deeply — became a co-sponsor of the Graham-Cassidy bill. (Estimates suggest Graham-Cassidy will cut federal dollars going to states for health care by up to $400 billion from 2020-2026, much less than the more than $700 billion in estimated Medicaid cuts that were included in some of the proposals Heller opposed.)
It’s not totally clear why Heller signed on to Graham-Cassidy. He may have assumed it would never actually come up for a vote. He may have been worried about re-election: Republican donors in Nevada were reportedly warning Heller that they wouldn’t give him money for his 2018 re-election effort unless he backed Obamacare repeal, and Trump suggested he would oppose Heller in a GOP primary if the senator didn’t join the cause. Or perhaps Heller simply believes in the Graham-Cassidy model of health care policy reform, which would send most Obamacare funds back to states.
Either way, co-sponsoring the bill was an odd move for Heller, largely because he had previously suggested he would back only legislation that both preserved the expanded Medicaid funding Nevada had received through Obamacare and had the support of the state’s GOP governor, Brian Sandoval. Even in July, it was clear that Graham-Cassidy would likely reduce the number of federal dollars going to Nevada for Medicaid, which is further supported by recent estimates. Sandoval didn’t endorse the legislation back then, and this week he joined a bipartisan group of governors opposing it.
Whatever his reasons, Heller’s support was key, making the Senate math much easier for Cassidy and Graham. Back in July, only three GOP senators (Collins, Heller and Murkowski) had been strong opponents of the Obamacare repeal bills, voting down both the full repeal of Obamacare and a partial repeal largely written by Senate Republican Leader Mitch McConnell. (Of the 52 GOP senators, the other 49 voted for at least one of those two provisions.)
The last-ditch “skinny” repeal bill (which did not include Medicaid cuts) was widely expected to pass because Heller supported it, providing what was thought to be the crucial 50th vote. But at the last minute, his “no” vote was replaced by McCain’s.
In other words, at the end of July, Republicans still had two months left to repeal Obamacare and only two real, solid opponents of their repeal ideas: Collins and Murkowski. They were the only ones to vote against all versions of the repeal, though a number of their GOP colleagues had also said they were reluctant to support various bills. Despite expressing concerns about protecting Medicaid, Sens. Shelley Moore Capito of West Virginia, Jerry Moran of Kansas and Rob Portman of Ohio all eventually voted for a version of Obamacare repeal that would have cut Medicaid spending. So did McCain, who said some of his objections to the “skinny” repeal bill were about the process by which it had been written (without any Democratic input and without going through the traditional committees and hearings). Mike Lee of Utah and Rand Paul of Kentucky, two of most conservative GOP senators, had voted for “skinny” repeal, despite complaining that the Obamacare repeal proposals left much of the ACA in place.
So assuming Murkowski and Collins were the only real holdouts, Heller’s support gave the Obamacare repeal 50 votes — at least in theory.
Meanwhile, Cassidy and Graham spent much of August and early September touting their bill. Senate Republican leaders were not enthusiastic about coming back from their summer recess to face another attempt at an Obamacare repeal. Neither were rank-and-file senators. But no senator was actually saying, “I will vote against this bill if it comes to the floor.”
Fast forward to this week and it’s easy to see why Senate Republicans want to give Obamacare repeal a final try. Yes, McCain is a problem, because this bill is, like the July legislation, a GOP-only proposal written outside of the traditional committee process. And he demonstrated in July that he is not afraid to be the deciding vote against an Obamacare repeal.
But McCain has not really given any policy-driven reasons for voting this bill down. And Graham is a very close friend of his. He may still vote yes.
Paul ultimately backed the skinny repeal bill in July despite his early objections, so Republican leaders are probably betting that his threats to vote against this bill are also empty. That’s not an unreasonable assumption.
Collins and Murkowski still sound like “no” votes, and they consistently voted “no” before. But if Collins and Murkowski are the only noes, the Republicans can pass Graham-Cassidy. So look for Paul and McCain to get plenty of calls from the White House and fellow Republicans imploring them to back this legislation, and for the Democrats to back off talking about Medicare-for-all for a bit. In short, the GOP is exactly where it was at the end of July, but with much less time left to get a deal done.