These are the new factions of the Senate health care debate

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Senate Republicans sound a little more upbeat about the prospects for Obamacare repeal. They reviewed their policy options at a conference lunch today, and while they still aren’t ready to make tough policy choices, there was a notable shift from the pessimism Sarah wrote about last week.

“We’re getting closer to having a proposal that we’ll be bringing up in the near future,” Senate Majority Leader Mitch McConnell (R-KY) said. Granted, that’s not much, but McConnell doesn’t say anything he doesn’t have to, and until now he had sounded downright downbeat.

We’ve seen two important points of progress. Axios reported that the Senate would still allow some waivers from Obamacare’s insurance rules, but would not allow states to waive the prohibition on plans charging sick people more than healthy people.

Some senators had been caught up on that issue, an important protection for people with preexisting conditions. The waivers the Senate reportedly might still allow could still adversely affect sicker people — if, for example, plans could exclude certain services from their benefits, as they would be permitted to do. But it is a potentially important political concession.

The other point was Medicaid, which has always promised to be the Senate’s toughest issue, because 20 Senate Republicans represent states that expanded the program under Obamacare. The House bill would have started to roll back the expansion in 2020.

Sens. Bill Cassidy and John Barrasso told reporters they were close to an agreement that would still phase out the expansion under their plan — but at a more gradual pace than the House. That may be the best win that senators preoccupied with Medicaid can hope for.

Don’t get me wrong: The policy questions are still thorny, and the math is still difficult.Republicans can only lose two of their own. But leadership is pushing ahead, both to pressure senators to get in line and to get health care over with, one way or the other.

As we get closer to an actual Senate bill, I think it’s worth reevaluating the politics of this and which members are important.

The conventional wisdom has been that the count is too tight, and maybe it is. But you can see a path for Senate leaders to run the table and get the votes they need.

  • The toughest moderate vote: Sen. Susan Collins of Maine. She opposes the House bill’s cuts to Planned Parenthood and is worried about rolling back protections for sick people. Collins is also reportedly considering a run to be Maine’s governor next year. Can she really vote for such an unpopular bill and expect to win?
  • The toughest conservative vote: Sen. Rand Paul of Kentucky. He hasn’t been engaged in the health care talks and wants to undo far more of Obamacare than most of his peers. Voting for any of the plans that have been publicized would be capitulation for Paul.
  • The moderates who want to get to yes: These include Sens. Rob Portman of Ohio, Cory Gardner of Colorado, and Shelley Moore Capito of West Virginia. They have been fighting to soften the Medicaid cuts, but in the end, people who have spoken with them think they may accept a slower phaseout of Medicaid expansion as enough of a win to support the bill. Cassidy could also fit into this group; he had positive things to say about the coalescing plan on Tuesday.
  • The conservatives who want to get to yes: These include Sens. Ted Cruz of Texas and Mike Lee of Utah. Unlike Paul, they have participated in the health care talks from the start. They surely won’t get everything they want, but if they can get something, they could get on board.
  • The Alaska wild cards: Sens. Lisa Murkowski and Dan Sullivan. Alaska is just a unique state. It expanded Medicaid. It also has the highest health care costs in the nation, so removing a geographic factor in the federal financial aid people receive to buy private health coverage, as the House bill did, could disproportionately harm their state. (Check out the estimates from the Century Foundation.) They might need something extra to help Alaska before they back the bill.
  • The 2018ers: Sens. Dean Heller of Nevada and Jeff Flake of Arizona. They face the toughest reelection races next year, and if the bill is going down, they might abandon ship. But are they willing to be the vote that stopped Obamacare repeal when they need GOP voters to turn out next year? That could be a stretch.

As you can see, it’s still tough. If Senate leaders lose Collins and Paul, they’d have to sweep the other wavering votes to pass the bill. But, for the reasons laid out here, it could happen



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