The Health 202: There are four kinds of GOP rabble rousers on health care

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THE PROGNOSIS

Rep. Shelley Moore Capito, R (W.Va.). (AP Photo/Tyler Evert)

About 218,000 more West Virginians would lack coverage under the Senate health-care bill. That’s way more than the 124,667 voters who boosted their now-Sen. Shelley Moore Capito (R-W.Va.) to her victory three years ago.

So it’s not surprising that Capito is among the ten GOP senators refusing to support the Obamacare overhaul in its current form – and one of the most vocal. She’d be okay with casting the vote that ultimately squashes the legislation, she told Politico in a recent interview.

“I only see it through the lens of a vulnerable population who needs help, who I care about very deeply,” Capito said. “So that gives me strength. If I have to be that one person, I will be it.”

If the Senate bill would cause ripples throughout the country with its cuts to Medicaid, there’d be a tsunami-like effect in West Virginia, which expanded its Medicaid program to the point that more than 30 percent of families rely on it. All told, the state’s uninsured rate would leap by 307 percent under the Senate bill as it currently stands, according to an analysis by the Urban Institute and the Robert Wood Johnson Foundation

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Like Capito, every senator opposing the bill for its deep Medicaid cuts is from a state that expanded the program under the Affordable Care Act (with the exception of Sen. Susan Collins of Maine). But the political posturing isn’t as blatantly obvious when you look at where the biggest uninsured increases would be and which senators are making the biggest fuss.

For example, Kentucky stands to see its uninsured rate rise by a whopping 231 percent under the Senate measure. Utah’s uninsured rate could leap by 78 percent and Wisconsin’s by 73 percent. Yet the conservative senators from those three states – Sens. Rand Paul, Mike Lee and Ron Johnson – are just fine with how the measure strikes Medicaid, instead taking issue with how it retains many of the ACA’s insurance regulations.

Other conservative-run states would see milder impacts under the Senate bill, but their senators are still expressing concerns about it. Sen. Jerry Moran of Kansas, where the uninsured rate would increase by 35 percent and there is no Medicaid expansion to phase out, recently surprised many when he criticized the Senate bill, saying he wants to ensure it sufficiently protects people with preexisting conditions.

Each Republican senator is making some hard personal calculations this week, as he or she considers how voting for the Senate GOP legislation would affect their constituents — and their reelection chances back home. I’ve identified four different camps into which the dissenters roughly fit:  The Medicaid Worriers; the Primary Positioners; the Ideologues; and the Noisemakers.

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Sen. Lisa Murkowski (R-Alaska) talking with constituents at the Wrangell, Alaska Fourth of July celebration. (Julia O’Malley for The Washington Post)

1. The Medicaid worriers.

These are the senators who fear a harsh backlash from voters if the ACA’s Medicaid expansion – which covers Americans who earn up to 133 percent of the federal poverty level – is phased out under their watch. The Senate bill winds down the extra federal payments from 2021 to 2023 but some senators including Dean Heller of Nevada have suggested that phaseout should be even slower.

Along with Capito and Heller, these senators include Rob Portman of Ohio and Lisa Murkowski of Alaska, whose states all expanded Medicaid under the ACA. Collins is also in this camp; onlookers such a position could be influenced by the possibility she might  run for governor in 2018.

“They’re simply looking at this from a practical political standpoint in their state and trying to figure out how to survive the phaseout of Medicaid expansion,” said GOP strategist Wes Anderson.

2. The primary positioners.

The biggest fear of these senators is that an Obamacare repeal bill leaves too much of the law in place, allowing an even more conservative challenger to oust them in a future primary election by claiming they voted to keep much of the ACA.

These senators, namely Sens. Ted Cruz of Texas, Mike Lee of Utah, Rand Paul of Kentucky, Ron Johnson of Wisconsin and Ben Sasse of Nebraska, are perpetually worried not about keeping their seat in a general election, but holding on in a primary battle. And the attacks from outside conservative groups that come with such a challenge.

3. The ideologues.

Many of the Primary Positioners are also ideologues, less affected by the numbers of people who might lose their health coverage and more affected by their own beliefs of how they could make the health-care system better.

And remember, Cruz, Lee and Paul won their seats in 2010 by campaigning on repealing Obamacare. Their worst fear is that Senate Majority Leader Mitch McConnell (R-Ky.) brings a bill to the floor that leaves much of the ACA in place, making it harder for them to argue they’ve repealed the entire law. Toward that end, Cruz is pushing hard for an amendment opting insurers out of more ACA regulations.

At the same time, it would be hard for Cruz or Lee (Paul is almost certainly going to vote against the Senate bill) to be the deciding vote against an Obamacare repeal bill no matter how weak they perceive it to be. It’s what they promised voters for seven years, after all.

4. The noisemakers.

Finally, there are a handful of relatively conservative Republican senators who are coming out of the woodwork to oppose the Senate bill for various reasons, but who may be more likely to vote in the end for whatever Obamacare repeal bill comes to the floor. They include Moran, and possibly Sens. Bill Cassidy of Louisiana (who himself is a doctor) and Bob Corker of Tennessee. Neither Kansas nor Tennessee expanded Medicaid; Louisiana did.

The Healthcare.gov website is seen on a laptop computer. (AP Photo/Alex Brandon)

AHH: Don’t look now, but the Obamacare marketplaces may have just had their most profitable first quarter ever. Marketplace insurers earned an average of nearly $300 per member in the first quarter of 2017, more than double what they earned in a similar period in the marketplaces’ previous three years, according to new analysis by the Kaiser Family Foundation. That figure puts insurers on track to make a profit in the marketplaces after years of losses, The Post’s Kim Soffen reports.

“The bountiful first quarter suggests the marketplaces are becoming a more profitable environment for the private companies selling insurance plans on the public exchanges,” Kim writes. There are still some big trouble spots next year, as 26,000 people across three states are at risk for having zero insurer options available to them next year. The evidence suggests insurers overall have been able to set premiums high enough for them to make a profit — but not so high that healthier customers are pushed out of the market, which is the recipe for market stability. 

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A nurse checks a patient’s blood pressure. (Photographer: Patrick Fallon/Bloomberg)

OOF: But if that’s the silver lining, here’s the rain cloud. The recent improvements in health-insurance coverage are eroding a bit. The country’s uninsured rate is creeping back up again, after reaching a record low under the ACA. About 2 million more adults lacked coverage in the second quarter, raising the uninsured rate to 11.7 percent from 10.9 percent at the end of last year, according to a Gallup survey. The survey reinforces recent government reports, which have found that progress in expanding insurance coverage mostly stalled five years after the ACA was passed.

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Vice President Mike Pence arrives in the Roosevelt Room of the White House. (Photo by Jabin Botsford/The Washington Post)

OUCH: Here’s another glaring example of the strategy dissonance between Mitch McConnell and the White House. Vice President Pence said yesterday that Congress should pass a repeal-only bill if they can’t agree on legislation to replace Obamacare, despite widespread warnings that such a two-step move would majorly disrupt health coverage for millions of Americans and cause market instability.

“If they can’t pass this carefully crafted repeal-and-replace bill, we ought to repeal only,” Pence said in an interview on Rush Limbaugh’s show.

McConnell and even other Trump administration officials, including Health and Human Services Secretary Tom Price, have shut down that idea even as it gained traction among some conservatives and Trump himself.

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Senate Majority Leader Mitch McConnell (R-Ky.) and Senate Majority Whip Sen. John Cornyn (R-Tex.) speak with the media. (AP Photo/Alex Brandon)

–It’s game-time. As the Senate returned to town yesterday, my colleagues reported that GOP leaders are aiming to show their rank-and-file a revised version of the health-care bill this week, with the aim of holding a vote next week.

From Sean Sullivan, who spoke with No. 2 Senate Republican John Cornyn:

The jury’s still out on exactly what will be included in the revised bill, but I laid out possibilities in Friday’s The Health 202. Expect to see a mix of policy changes appealing to both the moderate and conservative wings. Possible additions: An even slower phaseout of Medicaid expansion, extra funding for opioid abuse prevention, more opt-out from ACA insurance regulations, fewer cuts to Medicaid and insurance subsidies.

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Sen. Susan Collins (R-Maine) on Capitol Hill. (Photo by Melina Mara/The Washington Post)

–The changes better be drastic, Collins warned yesterday. The moderate senator, who is among the most likely Republicans to ultimately vote against the Obamacare revamp, told CNN she needs a “complete overhaul” before she’d come on board.

“It was really interesting being back home last week because the one and only (thing) that came up, no matter where I was, time and again, was health care,” said Collins, referring to her recess week back in Maine where constituents thanked her for opposing the Senate bill. “I do need a complete overhaul to get to a yes.”

Collins said that she wishes her GOP colleagues would look at the bill she introduced with fellow Republican Cassidy, which takes a different approach of allowing states to decide whether or not to preserve ACA provisions or ditch them. “I’m not claiming that bill’s perfect but it provides a foundation from where we could proceed,” she said.

She also added that she wants to work with Democrats — but is receiving unclear messages from Minority Leader Charles E. Schumer (D-N.Y.). “The Democratic leader has given very conflicting signals over whether or not he really wants to work with Republicans,” she said. “My hope is that we can avoid the mistake that President (Barack) Obama made when he passed a major health care reform bill, the Affordable Care Act, without a single Republican vote.”

Sen. Dean Heller, (R-Nev.) at a hearing on Capitol Hill. (AP Photo/Andrew Harnik, File)

–And then there’s Sen. Heller, another moderate deeply skeptical of the bill and has not been getting along so well with President Trump lately. The president is suspicious that Heller, and Sen. Jeff Flake (R-Ariz.) — another vulnerable Republican next year — are out to get him, Politico reports.

“Heller, who announced months before the election that he didn’t intend to support Trump, is out of favor with the president,” Alex Isenstadt writes. “The Nevada Republican recently came under attack from a pro-Trump outside group over his refusal to support the Obamacare repeal bill — a move that rankled Senate Majority Leader Mitch McConnell, who viewed it as an unnecessary effort to undercut one of his most politically vulnerable members.”

“Yet Trump has told friends that he loved the anti-Heller blitz, convinced that the senator was trying to use his opposition to the bill for his political gain and that a show of force was needed, said two people familiar with the discussions,” Alex writes. “When it comes to Flake and Heller, the disdain is personal — three sources familiar with the president’s thinking said Trump believes the senators are determined to undermine him.”

–Heller and other moderates are now facing a new round of ads from Save My Care, a coalition of groups opposing Obamacare repeal. The Heller ad includes footage of him forcefully coming out against the measure at a news conference last month. The group said it is spending more than $1 million on the new campaign.

All of this — the antagonism from Trump, the pressure from liberals back home — would make it very hard for Heller to vote for the Senate bill. From The Post’s Sean Sullivan on the new Save My Care ad: 

Some observers feel Collins and Heller are now the most likely Republican defectors on the Senate bill. From the MSNBC host:

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Sen. Tom Carper (D-Del.) walks with his wife Martha. (AP Photo/Patrick Semansky)

–Senate Democrats are playing little role in all this, except to protest all the Medicaid cuts and ACA rollbacks Republicans have put on the table. But some Democrats have identified potential new allies in their effort to scuttle it all: Republican governors, particularly those who helped expand Medicaid in their states under the ACA.

“Sen. Thomas R. Carper (Del.), who is leading the effort with the support of fellow Democrats, called ‘a couple dozen’ senators and governors from both parties over the recess…to say ‘this is a good time for us to hit the pause button in the Senate, and step back and have some good heart-to-heart conversations’ about how to revise the 2010 law,” my colleagues Juliet Eilperin, Sean Sullivan and Ed O’Keefe report.

“The development shows Democrats moving beyond rhetorical calls for bipartisanship to insert themselves into a legislative process that Republicans have dominated,” my colleagues write. “It also reflects continuing divisions within the GOP, with Republican governors emerging as potential allies for Democrats and others who oppose the current GOP proposal.”

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President Trump. (Photo by Matt Cardy/Getty Images)

–President Trump thinks Congress should skip August recess and keep working on health-care legislation, as some senators including Ted Cruz have suggested. This morning, the president retweeted this Cruz interview:

–Let’s be realistic: McConnell is highly unlikely to cancel August recess. The last thing he wants is to draw out all this drama over an unpopular GOP health-care bill. If he can’t zip things up in the next few weeks, he may just call it a day — and The Health 202 will be able to focus for a bit of this summer on getting a tan.

Some other good reads:

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(BRENDAN SMIALOWSKI/AFP/Getty Images)

Today

  • The House returns from July Fourth recess.

  • The Bipartisan Policy Center is holding an event on solutions to long-term care financing.

Coming Up

  • The Hazelden Betty Ford Foundation will hold a “national town hall” on Wednesday on the opioid crisis.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on examining medical product manufacturer communications on Wednesday.
  • The Hill is hosting an event on “The Cost of Caring: Family Caregivers and Tax Reform,” featuring Sen. Tammy Baldwin (D-Wis.), Sen. Joni Ernst (R-Iowa), Rep. Dan Donovan (R-N.Y.) and Rep. Michelle Lujan Grisham (D-N.M.) on Thursday.
  • The Bipartisan Policy Center will hold an event on Thursday on state flexibility in health care.

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