WASHINGTON — For Majority Leader Mitch McConnell, writing a Republican-only health care bill that can pass the Senate boils down to this question: How do you solve a problem like Dean, Lisa, Patrick, Ted, Rand and Susan?

Those are some Republican senators whose clashing demands McConnell, R-Ky., must resolve. Facing solid Democratic opposition to demolishing former President Barack Obama’s 2010 overhaul, Republicans will lose if just three of their 52 senators defect.

In a report that complicated McConnell’s task, the nonpartisan Congressional Budget Office delivered a damaging critique last week of the Republican-written bill that the House approved May 4. It concluded the measure would create 23 million additional uninsured Americans by 2026, lower premiums for younger and healthy people by letting them buy more sparse coverage, and confront unhealthy, poorer and older consumers with exorbitant out-of-pocket costs.

As Republican senators try privately crafting a bill, here are some problems facing McConnell:


Seeing that many people lose health care coverage is a nonstarter for many Republican senators. It’s a campaign attack ad that writes itself.


Republicans have to defend just nine of their 34 seats on next year’s Senate election map. Of them, just two seem competitive – Dean Heller of Nevada and Arizona’s Jeff Flake.

“Twenty-three million people. That’s a good place to start,” Heller said of why he opposes the House bill.

Most of those losing coverage would be Medicaid beneficiaries. People buying their own insurance and others getting coverage at work also would be hurt.

The number can be reduced by spending more on Medicaid, fattening tax credits for people buying insurance and boosting government payments to insurers to help them lower consumers’ costs. But those steps are complicated and expensive.


The House bill would halt extra federal funds in 2020 that 31 states get – Maine is not one of them – for Obama’s expansion of Medicaid, the federal-state health care program for poorer and disabled Americans. The legislation would also give states fixed federal sums annually, ending the open-ended payments that Washington has always made to reflect growing medical expenses and caseloads.


This means an $834 billion cut over the coming decade that would produce 14 million, or 17 percent, fewer Medicaid beneficiaries than projected, the budget office said. This is a problem for Republicans from states with a heavy reliance on Medicaid.

Twenty Republican senators are from states that expanded Medicaid, and most oppose abruptly ending the Obama law’s extra federal payments. They include moderates such as Sen. Rob Portman of Ohio, whose state Medicaid program has added 700,000 enrollees, and Alaska’s Lisa Murkowski, Shelley Moore Capito of West Virginia and Heller.

These senators are seeking a compromise that would phase out the extra federal expansion money for several additional years. They also want the overall program to grow yearly by a formula that’s more generous than the House would allow, and protect Medicaid money that states use to combat the growing problem of opioid abuse.

They also would increase federal payments to state pools for assisting low-earning residents, and federal tax credits that subsidize poorer people buying their own coverage.

Many conservatives want to curb Medicaid spending. In one proposal, they’d phase out extra federal Medicaid expansion money over a decade, but reductions would begin next year.

Sen. Patrick Toomey’s Pennsylvania has expanded Medicaid, but he’s also one of the Senate’s more conservative members. He’s seeking compromise with Portman on curtailing Medicaid, saying it “must be on a sustainable path.”



Conservative Republican Sens. Ted Cruz of Texas and Mike Lee of Utah want to erase Obama insurance coverage requirements. These include obliging insurers to charge the same premiums for healthy people and those with pre-existing medical conditions, and forcing them to cover specified benefits like maternity care.

Conservatives say without those requirements, people could buy less expensive though less robust coverage.

But many moderates are wary of a bill that would let Democratic opponents castigate them for snatching away coverage like maternity care. They also cite the budget office finding that letting states drop coverage requirements leaves many sicker and older consumers with untenably high costs.

Kentucky Sen. Rand Paul has repeatedly criticized the House bill for subsidizing insurance companies and is considered a conservative wild card.



Murkowski and Maine Sen. Susan Collins have opposed past conservative moves to block federal payments to Planned Parenthood, which provides abortions. The House bill does that and bars the use of federal health insurance tax credits for policies covering abortion.

Murkowski and Collins have not said such provisions would cause them to oppose an overhaul health care bill, but neither is comfortable opposing Planned Parenthood.


With its remoteness, high living costs and small pool of residents, Alaska has had the highest premiums in the U.S. since Obama’s law took effect, said Cynthia Cox, an associate director at the nonpartisan Kaiser Family Foundation. That means the House bill’s tax credits would be far smaller than Obama’s, which reflect premiums and incomes. That gap is a major problem for Murkowski.

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