Mitch McConnell's Precarious Health Care Balancing Act

With the revised bill – or bills – set to be unveiled Thursday, the GOP leader is in a tricky spot

Senate Majority Leader Mitch McConnell has called a meeting of all GOP senators Thursday morning ahead of the release of the new version(s) of the Obamacare repeal legislation. Credit: J. Scott Applewhite/AP

Senate Majority Leader Mitch McConnell announced Tuesday he was delaying a scheduled congressional recess by two weeks – the legislative equivalent of locking his conference in a room and telling them no one is leaving until this Obamacare repeal thing is sorted out once and for all. And indeed, on Thursday morning – shortly before one or more revised versions of the GOP health care bill are set to be unveiled – all Republicans senators are scheduled to convene at a meeting called by McConnell.

Still to be determined, with less than 24 hours to go, is which bill will be unveiled at that time. Multiple versions were submitted to the Congressional Budget Office for evaluation last week. (The CBO scores are expected sometime early next week shortly before the first procedural vote, which is set to take place mid-week.)

At least two versions are in contention: the revised version, and a version that also includes an amendment from Republican Sen. Ted Cruz. The Cruz amendment would remove the minimum coverage requirements imposed by the Affordable Care Act. It would make cheaper plans available, but they would be cheaper because they wouldn't cover many basic medical conditions. And, according to one study, the amendment would result in much higher premiums for some 1.5 million people with preexisting conditions.

The Texas senator's amendment has the support of fellow hardliner Sen. Mike Lee. It's been sharply criticized, though, by Sen. Chuck Grassley, who called it "subterfuge to get around pre-existing conditions." Sens. Shelley Moore Capito and Susan Collins have also expressed reservations about the impact the Cruz amendment would have on individuals with preexisting conditions.

That fight gets to the crux of McConnell's problem: He needs the support of both ultraconservatives like Cruz, Lee, Ron Johnson and Rand Paul, who also want to see the regulations imposed by the ACA repealed and costs driven down, and moderates like Grassley, Moore Capito, Collins and Dean Heller, who want to preserve protections for Medicaid enrollees and folks with costly, existing medical conditions.

The revised bill, sans Cruz's amendment, retains the deep cuts to Medicaid that many moderate senators said was a deal-killer after the Senate bill was introduced two weeks ago. In a press conference shortly after the bill debuted, Heller said he would not support it because of those Medicaid cuts. "You have to protect Medicaid expansion states. That's what I want," Heller said. A number of his Senate colleagues, including Moore Capito, Lisa Murkowski, Rob Portman and the Republican governors of several states that expanded Medicaid coverage under the ACA, sounded similar concerns.

There are other sticking points for GOP senators over language that would defund Planned Parenthood (Collins and Murkowski oppose such efforts), the rumored retention a tax on the wealthiest Americans (Collins and Bob Corker support keeping the tax) and insurance subsidies (Paul and Johnson want less money spent on them).

McConnell can only lose the support of, at most, three Republican senators and still manage to pass the thing. It's hard to see how he comes up with a compromise that satisfies enough members of his conference, even with the promise of $45 billion in funding to help fight the opioid crisis in states where the proposed cuts to Medicaid could dramatically aggravate the crisis. We will know in the next week whether that's enough to carry this beleaguered bill over the finish line.