The Senate’s health-care bill could go down in flames any number of ways. And after a nonpartisan congressional report estimated Monday the Senate bill could cause 22 million more people to lose their health insurance over the next decade while raising out-of-pocket costs for elderly and low-income Americans, it’s at risk of death by half a dozen mini fires.
Here are the five factions in the Senate that are coalescing against this bill and could make it a very real possibility that it fails, perhaps even before leaders bring it to a vote this week
1) The no-repeal, no-deal faction
Think of this group of senators as the conservative purists. The Senate bill (and an earlier version passed by the House of Representatives) keeps the structures of Obamacare in place, mostly because policymakers can’t knock out the foundation without the whole house (the health insurance market) sinking in.
That’s not good enough, say this group of senators. We campaigned on repealing Obamacare; we should do it.
Who’s in this group: It’s led by Sen. Rand Paul (R-Ky.) and closely followed by Sens. Ted Cruz (R-Tex.) and Mike Lee (R-Utah). All three told reporters Monday they’d be inclined to vote against a key procedural vote to move the Senate’s health-care bill forward. Three Republican “no” votes would be enough to stop the bill before it got to a final up-or-down vote.
What they want: To wait to repeal Obamacare until Republicans have an actual replacement. The problem with that is that leaders only have a limited window to get health-care policy done in a way that avoids a Democratic filibuster. Leaders want to move onto overhauling the tax code instead of spending a whole year on health care like Democrats did in 2010.
What they’re saying: “Republicans were elected to repeal Obamacare, not to keep Obamacare,” Paul told reporters Monday.
2) The keep-the-rug-underneath-people faction
This group of more moderate GOP senators may not like Obamacare, but they also recognize that thousands in their states have gotten insured because of it. And they can’t vote to take that health insurance away. The Congressional Budget Office estimated that some of the 22 million people would willingly lose their insurance because they would no longer be required by law to have health insurance. Others, though, would unwillingly lose their insurance because they wouldn’t be able to afford it, as the federal government cuts down subsidies for lower-income and elderly Americans and people on Medicaid over the next decade.
Who’s in this group: Sen. Dean Heller (R-Nev.), who could lose reelection next year in a state that voted for Hillary Clinton. Also Sen. Susan Collins (R-Maine). Both indicated they, too, would vote against a key procedural vote required to advance the legislation.
What they want: More federal money for people who are on Medicaid. The CBO projects this bill would cut $772 billion over the next decade, leaving the 31 states that expanded Medicaid under Obamacare to figure out how to write the check for the federal program — or just no longer insure these people.
What they’re saying: “I cannot support a piece of legislation that takes away the insurance from tens of thousands of Nevadans,” Heller said in a Friday news conference. (Nevada has cut its uninsured population by half under Obamacare.)
3) The process faction
This group of senators isn’t happy with how uncharacteristically speedy the Senate has moved on this bill. It was written in secret by Senate Majority Leader Mitch McConnell (R-Ky.), then shared just a week before an expected vote.
What they want: More time to read, debate and tweak the bill. The normal process for legislation takes months, and several Senate committees would have held public hearings on the bill before a vote.
Who’s in this group: Sen. Ron Johnson (R-Wis.), who is also arguably part of the no-repeal, no-deal faction. And, it’s safe to assume quite a few undecided GOP senators who haven’t publicly commented on the legislation are frustrated with the process. (We count some 27 undecided or unclear GOP senators.)
“I don’t think we should be voting on this bill this week at all,” Johnson told NPR’s Rachel Martin. “I think we need more time to gain feedback from our constituents, really review the bill.”
4) The 2020ers
This group of GOP senators is up for reelection in 2020. Shortly after, this Senate bill would have the federal government phase out its support for an estimated 11 million people who got insured by Obamacare’s Medicaid expansion.
If health care is still a campaign issue, voting for this bill could put these potentially vulnerable GOP senators on the spot for people who lose insurance in their states. “Voting for this repeal bill means you’re on the wrong side of history and also more likely history in your next re-election,” said Democratic strategist Jesse Ferguson.
Who’s in this group: Sen. Cory Gardner from the swing state of Colorado (who is the chair of Senate Republicans’ 2018 reelection committee), Collins of Maine, Sens. Joni Ernst from Iowa, Steve Daines of Montana and Dan Sullivan of Alaska are all potential Democratic targets.
What they want: It’s unclear. Interesting, all of them save Collins are undecided.
What they’re saying: They’ve offered very constituent-focused statements, like this from Sullivan: “I believe that we can do better for our state and our country, but I will not vote for a bill that will make things worse for Alaskans.”
All 48 senators who caucus with the Democrats are expected to vote against this legislation. But that won’t matter because of the way Republicans are moving this bill. Republicans are tying this bill to a parliamentary budget rule called reconciliation that allows them to avoid a filibuster by voting on anything that impacts the federal budget. That means instead of requiring 60 votes to pass, this bill only requires 51.
But if Republicans can’t pass this bill in the next couple weeks, their window to duck a Democratic filibuster will close. If they revisit this in the fall or next year, for example, Democrats could filibuster this legislation. And that’s a fact Senate Republican leaders are keenly aware of as they try to rush a vote this week, despite five factions being against them.