September 21, 2017

Pressure Points on the Obamacare Repeal

Meet the nine Senators who stand between Trump and the Affordable Care Act

by Chris Thomas

If the Republican Party is going to repeal the Affordable Care Act (details on the repeal bill here) they’re going to do it by the end of September but, as of this writing, it looks as if Senate Majority Leader Mitch McConnell lacks the votes to pass a repeal, even under Reconciliation rules. The vote swings on nine senators; if one of them represents you, your voice can change history.

Lisa Murkowski (R-AK)

Murkowski is a moderate Republican who’s been non-committal on the Cassidy-Graham repeal. She was instrumental in the defeat of the GOP’s previous repeal but has not overtly rejected this one, stating that she “needs to see more data.”

Medicaid and Alaska’s Bottom Line

And that data is almost certainly Medicaid per-capita expenditures. Alaska is among the states scheduled for a billion-dollar cut under Cassidy Graham’s presumed $4,400 subsidy per “eligible beneficiary” but the financial projections out of Senator Bill Cassidy’s office seem to call for a 48% bump for Alaska, bringing their per-capita total to $6,500. This “Alaska Purchase” may be an attempt to buy Murkowski’s vote, though it may also be unconstitutional.

Shelley Moore Capito (R-WV)

West Virginia used to be a stalwart Democratic stronghold but the waning influence of unions and the environmental movement’s rejection of coal has driven the state into the arms of the GOP. Capito is well aware of how conservative her state is but while politics favors repeal, it will come with a cost.

Opioids and Medicaid

West Virginia is ground-zero for the opioid epidemic. Decades of back-breaking labor in conjunction with the plummeting price of renewables and the overall mechanization of the coal industry have left coal mining towns a desolate wasteland of epidemic addiction. As a result, while West Virginia residents voted overwhelmingly for Trump, the economic realities of a billion-dollar Medicaid shortfall without any substantive aid on the opioid issue will hit them especially hard.

Rob Portman (R-OH)

Portman’s Ohio is in much the same situation as West Virginia, though with much thinner political margins. The quintessential swing state, Portman knows that Ohio will judge him by the deal he delivers.

Opioids and Medicaid

Like West Virginia, Ohio is in the throes of an opioid epidemic with no help in sight, but unlike West Virginia, Ohio stands to lose nearly ten-times as much in Medicaid funding: some $9 billion dollars.

Lamar Alexander (R-TN)

If anyone is in the thick of this issue it is Lamar Alexander, who chairs the Senate health committee. Like McCain, Alexander would prefer a return to regular order and a bi-partisan attempt to shore up some of the issues with Obamacare.

Responsibility and Reconciliation

More than any other Republican Senator, Lamar Alexander is likely thinking about what it means to live with Cassidy-Graham. The Republican Party has spent the last 8 years hanging the Affordable Care Act around Obama’s and the Democrat’s neck like an albatross and if Cassidy-Graham passes with all of its chaos, budget shortfalls, and other issues it will hang around few necks more than Lamar Alexander’s.

Mike Lee (R-UT)

Senator Lee and Senator Rand Paul share a dislike of all things Obamacare and, to both of them, Cassidy-Graham doesn’t go far enough. Unlike Senator Paul, however, Senator Lee is much less likely to let that get in the way of the GOP’s last shot at a repeal.

Taxes

Utah does fairly well under the Cassidy-Graham proposal, picking up a modest bump in Medicaid funding but the remaining taxes still baked into the bill certainly irritate Senator Lee.

Jerry Moran (R-KS)

Senator Moran is still “undecided” on Cassidy-Graham though why is anyone’s guess. Moran has supported every repeal effort thus far with little call for conditions or substantive change. If anything, he may view the measures as an insufficiently complete rollback of Obamacare.

Future Shortfalls

Kansas picks up an additional $2 billion in Medicaid grants under the bill but that money will vanish in 2027 and create a gaping hole in the state’s budget. Free money is still free money so it’s unlikely that Moran will vote against it for fear of its withdrawal in 10 years but such justifications were common enough when it came to rejecting the Affordable Care Act’s Medicaid expansion.

✔️Rand Paul (R-KY)

Paul Is Voting No!

In a September 15th tweet, Senator Paul wrote: “I can’t support a bill that keeps 90% of Obamacare in place.”

Rand Paul is a hardliner when it comes to Republican politics and so his opposition to the Graham-Cassidy repeal is because it does not go far enough.

Taxes, Spending, and Medicaid

Paul says the bill “keeps 90% of Obamacare spending and 90% of Obamacare taxes” and, at least through 2026, he’s not wrong. Paul might also take issue with Kentucky’s $5 billion loss of Medicaid funds under the bill, which would divert money from his state to Mississippi, Alabama, and Georgia. In response to escalating pressure from the White House implying that he would be “the Senator that saved Obamacare,” Paul wrote:

✔️John McCain (R-AZ)

McCain Is Voting No!

In a statement on Twitter on September 22nd, McCain wrote “I cannot in good conscience vote for Graham-Cassidy.”

McCain’s mic-drop moment in the July vote on the “skinny repeal” prompted many to wonder if his struggle with a brain tumor had changed his views on healthcare and his commitment to bi-partisanship as Graham-Cassidy comes down to the wire reaffirms that.

A Lion of the Senate

McCain is one of the most respected members of the Republican party and his primary concern is likely his legacy both as a Senator and a party leader. McCain’s statement is just that: a statement. Statements can be reversed; a legacy is built with action.

✔️Susan Collins (R-ME)

Collins Is Voting No!

Senator Collins announced that she would vote against Cassidy-Graham on September 25th, providing the 3rd and likely final Republican “no” vote on the bill.

A Brutal Bill

Collins’ objections to the bill most closely parallel those of Democrats, which is no surprise given the left-leaning politics of Maine in general. Collins is a moderate Republican with an emphasis on “moderate;” a repeal for partisan reasons without a well-fleshed-out policy to protect the populations served by Obamacare would be very unpopular in her state. CNN summarized her reasoning as follows:

“Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,” Collins said. The bill would also “open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis and diabetes.”

Everyone Else

The following Senators are are either undecided or have not made a position public according to CNN. Each Senator will have their own reasons for voting, but as the $4 trillion in Medicaid cuts are the financial elephant in the room, the following listing shows what changes to Medicaid each “unclear” Senator could expect to see for their state through 2026.

  • Dan Sullivan (R-Alaska) — $1 Billion lost
  • Cory Gardner (R-Colorado) — $6 Billion lost
  • Johnny Isakson (R-Georgia) — $10 Billion gained
  • David Perdue (R-Georgia) — $10 Billion gained
  • Todd Young (R-Indiana) — $2 Billion lost
  • Marco Rubio (R-Florida) — $4 Billion lost
  • Joni Ernst (R-Iowa) — No change
  • Chuck Grassley (R-Iowa) — No change
  • Pat Roberts (R-Kansas) — $2 Billion gained
  • Steve Daines (R-Montana) — No change
  • James Lankford (R-Oklahoma) — $3 Billion gained
  • Pat Toomey (R-Pennsylvania) — $6 Billion lost
  • John Thune (R-South Dakota) — $1 Billion gained
  • Bob Corker (R-Tennessee) — $3 Billion gained
  • Ted Cruz (R-Texas) — $35 Billion gained

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