WASHINGTON — To understand the dilemma facing Senate Republicans as they struggle to repeal Barack Obama’s health care law, just talk to Susan Collins of Maine and Rand Paul of Kentucky.
They represent the competing poles within the GOP caucus that majority leader Mitch McConnell must satisfy to piece together 50 votes.
Collins and several other key moderates are exerting outsized influence on the debate — and they show little sign of backing down. They worry that the House Republican plan would strip insurance from millions of Americans with preexisting conditions and inflict unacceptably deep cuts on Medicaid.
On the opposite end of the spectrum, Paul and other Senate conservatives want to eradicate all vestiges of Obama’s Affordable Care Act, including its insurance market interventions and costly Medicaid expansion. They’ve spent seven years promising voters this opportunity would come.
Can the gap be bridged before McConnell’s self-imposed Fourth of July deadline?
“I have no idea,” said Collins, when asked late last week if she was confident Senate leaders could produce a bill she can vote for. “This really is a work in progress and until I see the bill and the [Congressional Budget Office] assessment of the bill, I’m not going to feel comfortable taking a position.”
Her conservative counterpart was no more certain of the outcome.
“It’s unknown,” said Paul. “My promise to the voters was to repeal Obamacare, and it looks more like we’re keeping a good chunk of Obamacare.”
The predicament is so thorny that McConnell is keeping the deliberations under a deep wrap of secrecy, hoping to delay a public split over specific aspects of the legislation that could ruin the negotiations. Vice President Mike Pence would break a 50-50 tie, so McConnell can spare just two defections from the 52-member Republican caucus.
That narrow margin gives the most outspoken critics powerful leverage over the final shape of the bill. Collins is among those who essentially agree with President Trump’s reported assessment that the House-passed bill is “mean” and that the Senate version needs to be more sensitive to consumers and the working poor.
A sign of Collins’s influence: Trump asked her at a lunchtime meeting of GOP senators last week to talk about her criticisms of the House bill’s reliance on creating so-called “high-risk pools” to help people with preexisting medical conditions afford health coverage.
“I thought that that was good,” Collins said of Trump’s request. Perhaps that could be counted as progress, but it’s hardly a ringing endorsement of the Senate’s negotiations.
The House bill allows states to opt out of the current law’s prohibition on insurers charging patients with preexisting conditions like cancer, diabetes, or high blood pressure more for coverage.
To address concerns about that change, House GOP leaders added several billion in federal funding to help states pay for high-risk pools to help sick patients afford coverage, but it is not nearly enough, Collins said. A former head of Maine’s insurance bureau, Collins said she grew frustrated at House lawmakers invoking Maine’s experience with high-risk pools as justification for that idea.
In May, Collins gave a lunchtime presentation to the Senate GOP caucus on how a high-risk pool would operate and “to point out that the House bill grossly underfunded it,” she said.
“I’m not sure [the Senate bill] will end up being more to the center,” Collins said. “We’re having very vigorous debates.”
Alaska Senator Lisa Murkowski, another member of the moderate Republican wing, was blunt. Asked if she thought McConnell would produce a bill she could support, she replied, “I just truly do not know. Because I don’t know where it’s going.”
The public knows even less. GOP senators have been remarkably tight-lipped about the contours of the policy issues being hashed out both in the smaller working group McConnell convened to tackle big divisions and in the caucus at large, which has been devoting several lunchtime meetings a week to discussing the bill. Senators, even those close to McConnell, say they haven’t seen actual legislative text. They just know the outlines of various policy options on the table.
“There’s no bill as far as I know,” said Ohio Senator Rob Portman, part of the moderate group that has been working to push the Senate bill leftward.
Republican leaders defend their process, saying they’ve held dozens of hearings on flaws since the health law was approved in 2010. “We’ve been dealing with this issue for seven years. It’s not a new thing,” McConnell said last week. “We understand this issue pretty well, and we’re now working on coming up with a solution.”
A major point of contention is how deeply and quickly to cut the federal funding for the law’s Medicaid expansion, which helped millions of people gain health insurance. Twenty GOP senators represent states that embraced the expansion.
Moderates, led by Portman, are arguing Congress needs to move slowly on rolling back the expansion, to give governors of states that did expand Medicaid time and flexibility to figure out how to ensure continued coverage for at least some of the newly insured.
Portman — whose home state is among those that took advantage of the Medicaid expansion — has pitched colleagues on a seven-year phase-out, while conservatives want quicker action.
Another key disagreement is how generous the tax credits for low-income people should be, with another stark moderate-conservative divide.
Paul, the Kentucky Republican, complained that the thrust of the GOP bill is to subsidize rather than fix the individual health insurance markets that he says are in a “death spiral’’ because of Obamacare. Paul said he satirically proposed in a recent caucus meeting that they also embrace a similar approach to the high cost of college education and dump $70 billion into making it more affordable.
“Those things just aren’t Republican principles,’’ Paul said, “and I don’t know how we strayed so far from repealing Obamacare.”