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Mitch McConnell started the Senate health care debate with an impossible task: reconciling the bitter differences between his conservative senators who wanted to undo as much of Obamacare as possible and more moderate members who were skittish about millions of people losing health insurance.
Now he's given up. The Better Care Reconciliation Act was left for dead Monday night when four senators refused to back the bill and half a dozen more, all moderates, remained undecided. Two months of backroom negotiations and mounting pressure for senators to deliver on their promise to repeal and replace Obamacare still left the plan short.
But the underlying cause of death was the lack of a coherent health care policy vision within the Republican Party.
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Conservatives wanted to unwind as much of Obamacare as they could, whatever the consequences. Moderates were skittish about passing a plan that would lead to millions of people losing health coverage they gained under Obamacare, openly advocating to keep some of the most popular provisions of the 2010 health care law. The two ends of the ideological spectrum also struggled to agree on how deeply to cut Medicaid, both by ending Obamacare's expansion and by putting a hard spending cap on the whole program.
Faced with that reality, McConnell announced late Monday night that he would instead try to force a vote on a bill that would more fully repeal Obamacare with a two-year delay for Congress to figure out a new plan for how to replace it.
But it's not clear that bill would have the 50 votes it needs to pass either. The GOP's hopes for any kind of health care achievement to fulfill seven years of campaign promises are rapidly dimming.
McConnell has compared his health care problem to a Rubik's cube: The most moderate and most conservative members of his caucus both oppose the current bill, and he needed to twist the policy into some configuration that would get 50 votes.
But by Monday night, moderate Susan Collins (R-ME) and conservative Jerry Moran (R-KS) had called for starting over from scratch. Sen. Rand Paul (R-KY), maybe the most stalwart opponent of the current bill, seemed almost impossible to win over.
Sen. Mike Lee (R-UT) at least made his demands clear. But McConnell lost Paul and Lee for different reasons than he lost Collins — a perfect encapsulation of his struggle to craft a plan that could win 50 of the 52 Republicans in his conference.
Collins opposed the bill for its projected coverage losses and Medicaid cuts. By slashing Medicaid and dialing back the financial assistance for people who purchase private coverage, the original bill was projected to lead to 22 million fewer Americans having health insurance in 2026, versus Obamacare. It was also estimated to cut Medicaid spending by $772 billion over 10 years, versus current law. The result would be 15 million fewer people enrolled in the program.
Paul, meanwhile, had overarching problems with the bill. He argued it didn't repeal all of Obamacare's taxes or do enough to roll back the law's insurance regulations. But he reserved special ire for the $182 billion in "stabilization funding" that would be funneled to insurance companies to help cover people with high medical costs. He derided that money as an "insurance bailout superfund."
Lee's objection was very specific: He was not satisfied with the version of a proposal by Sen. Ted Cruz, his close ally, that was included in the current bill. Cruz's amendment would allow insurers to sell plans that didn't comply with Obamacare as long as they also offered plans that did. But Lee, writing at the Resurgent, said he was unsatisfied with the way the proposal was structured. He wanted insurers to be able to separate people insured under Obamacare plans from those insured under the other plans into two separate risk pools, arguing it would make premiums lower for the noncompliant plans.
Moran's problems with the bill were a little more opaque, though he faced rowdy protesters during his town halls back home in Kansas.
"This closed-door process has yielded the BCRA, which fails to repeal the Affordable Care Act or address health care-rising costs," the senator said in a statement. "For the same reasons I could not support the previous version of this bill, I cannot support this one."
The Senate bill polled terribly. The Congressional Budget Office found 22 million fewer people would have insurance in 2022, compared with Obamacare. The Cruz amendment would have undermined the law's protections for people with preexisting conditions. The Medicaid changes would cut deeply into the program.
But none of that quite killed the bill. More conservatives defected from the plan than moderates, because it didn't undo Obamacare enough.
Though many Republicans voiced their support for maintaining the health care law's protections for people with high medical costs, none of them, aside from perhaps Collins, had objected to the revised bills on those grounds.
A half-dozen GOP senators focused on the Medicaid provisions — most notably Sens. Shelley Moore Capito (R-WV), Rob Portman (R-OH), Dean Heller (R-NV), and Lisa Murkowski (R-AK) — were officially undecided on the plan. They had not yet come out against the bill before Lee and Moran announced their disapproval.
Even Heller, who faces the toughest reelection race in 2018 and aligned himself with his state's very popular Republican governor, who opposes the bill, was still on the fence Monday night.
Nevertheless, their hesitance to back the bill further complicated the puzzle for McConnell. It's possible they never would have come around to support the bill, given its deep cuts to Medicaid. Murkowski chastised McConnell in a closed-door meeting for trying to overhaul the program as part of the Obamacare repeal effort, per Politico. Capito, usually a leadership ally, represents a state where one-third of families are on Medicaid.
By trying to totally remake Medicaid at the same time they repealed Obamacare, Republican leaders added another volatile variable to an already delicate political debate.
McConnell is now giving up, at least for now, on repealing and replacing Obamacare in a single bill. He is now trying to force a vote on the 2015 bill that congressional Republicans passed repealing much of Obamacare, with a two-year delay for Congress to figure out a new replacement plan.
President Donald Trump took quickly to Twitter on Monday night and appeared to endorse that course of action.
But for procedural reasons, the Senate would first need 50 votes to start debate on the repeal-and-replace plan before McConnell can force a vote on the clean repeal bill. It's not clear he can get enough support for that procedural vote.
Even if he did, it seems doubtful that enough Republicans would support a clean repeal, which would mean millions of Americans losing their health insurance. The Congressional Budget Office estimated in 2015 that the bill Republicans are now returning to would lead to 32 million fewer people having health coverage compared with Obamacare.
Republican lobbyists have told me repeatedly that McConnell is fixated on winning. But he seems to have decided that Republicans have wasted enough of their political capital on trying and failing to pass a bill that is even more unpopular than the health care law they loathe.
If the repeal vote also fails, it might be time for Republicans to give up the ghost of Obamacare repeal entirely and move on to smaller fixes to the health care system.
In the coming months, McConnell could turn to a bipartisan stabilization bill, as he threatened to do while trying to pressure Republicans to back the current plan. Obamacare has had legitimate problems keeping insurers in the market and, by extension, options available to consumers. More funding to stabilize the markets is a concept with support among Republicans and Democrats.
He could also rely on some upcoming legislative items to score health policy wins. The Children's Health Insurance Program needs to be reauthorized later this year. Another set of smaller health care programs and provisions must also be approved once again. That kind of must-move legislation always becomes a vehicle for other policies, which could give Senate Republicans an opportunity shape federal health policy more to their liking.
It's too soon to tell. But people in Washington are already starting to turn toward the future, even if the American Health Care Act and Better Care Reconciliation Act seem to be dead for now.
"Anyone who thinks Republicans are walking away from all the policies in AHCA/BCRA are not paying attention," another Republican health care lobbyist told me.