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Republicans Are Still Seven Votes Shy On Health Care

Republicans appear to be at least seven votes short of the 50 they need to get a health care bill through the Senate, which is basically where they were when Senate Majority Leader Mitch McConnell unveiled a draft bill more than two weeks ago.

Soon after the draft bill’s release, one bloc of GOP senators (Ted Cruz of Texas, Ron Johnson of Wisconsin, Mike Lee of Utah and Rand Paul of Kentucky) argued that the bill was insufficiently conservative and did not repeal enough of the Affordable Care Act, aka Obamacare.

A separate bloc of more moderate Republican senators (Shelley Moore Capito of West Virginia, Susan Collins of Maine, Dean Heller of Nevada and Rob Portman of Ohio) said the bill was too conservative. Lisa Murkowski of Alaska, another more moderate Republican, has been noncommittal about backing the bill.

There are 52 Republicans in the Senate — the bill has no support from non-GOP senators — so leadership can afford to lose only two in a vote (with Vice President Mike Pence as the tiebreaker to push the tally to 51). If this process were going well for Republicans, by now some of the hesitant members would have proposed changes to the bill, McConnell would have said he is adopting those changes, and these members would say they were voting for the bill, pending those changes. That full cycle has not happened yet with any of these nine members. Some have publicly proposed ideas that McConnell has not yet said he will adopt, presumably because he knows those ideas won’t fly with other members. Others have not, at least publicly, given any kind of wish list, suggesting that they would like the bill to die.

I would say Republicans are stuck in neutral, except that they might be moving backward, adding opponents to the legislation. Two stalwart Republican senators (North Dakota’s John Hoeven and Kansas’s Jerry Moran) criticized the McConnell bill last week, although I’m skeptical that either would be a “no” if the legislation moved to a vote.

McConnell and other Republicans seem to be increasingly pessimistic that Republicans can come together. And a close look at these nine senators and their public comments suggests that this pessimism is grounded in reality. (We grouped some of the senators below to illustrate how interconnected some of their concerns are.)

Dean Heller

The Nevada senator sharply criticized McConnell’s bill the day after it was released, arguing that its cuts to Medicaid were much too deep and that it was a “lie” to claim that the bill would lower health care premiums for Americans. Heller has said little publicly about the legislation since then. That’s not good for Republicans, because his initial opposition was strong and there is little indication that Heller is working with Republican leaders to push for changes to the bill that would bring him closer to voting for it.

Susan Collins

Like Heller, Collins was strongly against the bill from the start; she shared the Nevada senator’s concerns about Medicaid and affordability. She has continued to make public comments on the legislation — but they suggest that she is moving further away from it. She told The Washington Post that at a Fourth of July parade in Eastport, Maine, some of her constituents had praised her for opposing the legislation. Collins also told the Post that she has been talking to Democrats about pursuing bipartisan legislation if McConnell drops his push to pass a health care bill with only Republican votes.

One other thing about Collins and Heller: They are both from states that Hillary Clinton won in 2016. And Heller is up for re-election next year. They have political and policy reasons to object to this legislation.

So let’s consider them two “no” votes. That means for the Senate bill to pass, McConnell needs all seven of the remaining critics of the legislation to back it. Right now, that looks very unlikely to happen.

Lisa Murkowski

While in Alaska last week, Murkowski suggested that she was being left in the dark about the legislative process by Senate Republican leaders. The Alaska senator also said that she, like Collins, is interested in working with Democrats on a bipartisan bill. Those are not great signs that she wants to work with McConnell on a revised version of a GOP-backed bill.

Ted Cruz, Mike Lee and Ron Johnson

We described last week a three-part plan for Republicans to pass the bill through the Senate: loosen some of the insurance requirements, as conservatives want; reduce the cuts to Medicaid and add money to fight the opioid crisis, as some moderates have urged; and appeal to party loyalty to get other reluctant Republicans behind the legislation.

Cruz is touting a proposal that would let insurers sell plans that do not include all the essential benefits mandated under Obamacare, as long as those insurers sell some plans that do include these benefits. (Health care experts say this approach is likely to result in cheaper plans for healthier people and much more expensive coverage for people who already have health problems.) Lee’s spokesman has said that the Utah senator will back McConnell’s bill if this provision is included. Johnson has said little publicly since his initial opposition, but he has allied himself with Cruz and Lee in this process and seems likely to back the bill with this change as well. (An op-ed that Johnson wrote in The New York Times echoes some of the general ideas of the Cruz proposal.)

It’s safe to assume that Cruz also would support the bill if this provision were included.

So that’s good news for McConnell: The conservative bloc could be placated.

Here’s the bad news: The conservative bloc may be becoming insistent on this particular provision. Lee’s spokesman told Axios that the senator would back the Senate bill only if this provision were added. Cruz has hinted that he has a similar view. Such absolutism is problematic for McConnell, who probably needs senators to stay flexible on the exact language of the bill.

But the bigger problem with the Cruz proposal is …

Shelley Moore Capito

Capito told the Charleston Gazette-Mail’s Jake Zuckerman that she opposes the Cruz proposal. She said it undermines protections for people with pre-existing conditions, who might be unable to afford premiums under the system that Cruz proposes.

This is significant. Typically, a change in a bill that would bring in three votes would be worth turning off one senator. But remember — if Collins and Heller are already against this legislation, McConnell can’t afford any more “no” votes. So if the Cruz proposal takes away Capito’s vote, McConnell probably can’t add it to the bill. This may explain why McConnell has not publicly committed to including the Cruz provision in the legislation.

Capito also suggested that she thinks the legislation cuts Medicaid too deeply.

And there’s another problem with getting Capito’s vote: her public vagueness. Cruz and Lee are being specific. They have discussed policy changes that they want to see in the bill and have laid those out in public. If the Cruz provision is in the bill, Lee has essentially committed publicly to voting for it.

In contrast, Capito’s concerns are more vaguely defined (at least publicly — she might have handed McConnell a detailed, specific list in private). It’s difficult to know whether she opposes the $772 billion in Medicaid cuts, compared to funding under existing law, that the Congressional Budget Office says is one outcome of the McConnell draft bill, but would be fine with $400 billion or $200 billion.

Rob Portman

Portman has allied himself with Capito in pushing for more funding to fight the opioid crisis and fewer cuts to Medicaid. He has been quieter about his views about the bill recently, but there is no indication yet that he will back it or that he has a list of specific changes that he wants.

Rand Paul

Paul has been as critical of the McConnell draft as Collins and Heller, but his criticism comes from the right. There is no indication that he thinks the Cruz provision will address his core argument, that the outlines of Obamacare will remain law if any version of the McConnell draft passes. He blasted the legislation on the Fox Business network last week.

I didn’t include him in the “no” group with Collins and Heller only because Paul has political incentives to back this legislation: Trump won by 30 percentage points in Kentucky.

A lot of news coverage over the last week has focused on comments from Republican senators like Chuck Grassley of Iowa and John McCain of Arizona that downplayed the likelihood of the bill’s passage. I don’t put much stock in these senators essentially playing pundit. Neither has laid out a deep, substantive critique of the bill’s contents, and I assume both would back it in a formal vote. I take their comments as lagging indicators of what I laid out above: Grassley and McCain can count votes the same way you and I can, and they see that the bill is well short of the support it needs.

There is likely to be a lot of news coverage the next few weeks that focuses on McConnell’s legislative skills or Trump’s strategy on health care. I would discount much of that. The fundamental question is whether at least seven of these nine Republican senators will accept a bill that is either more conservative or less conservative than they would like.

So far, these nine aren’t sounding like they will accept many compromises.

Perry Bacon Jr. was a senior writer for FiveThirtyEight.