Sen. Dean Heller (R-Nev.) occupies a unique position. He is the most vulnerable Republican senator on the ballot in 2018 in a state that, as a result of the Affordable Care Act’s Medicaid expansion, made 204,000 people (a 90 percent increase) “newly eligible for coverage, most of them childless adults who are working but whose employers do not offer health insurance coverage.” This is the working poor, in other words.

Nevada’s Republican governor has been among the most vocal GOP opponents of House Republicans’ American Health Care Act, for obvious reasons. His state will face horrid human and political consequences if either the House bill or the Senate bill, which cuts Medicaid more than the House bill over the long term, becomes law:

[Brian] Sandoval is one of five Republican governors — in states that have expanded Medicaid — pushing to keep Medicaid expansion intact or replace it with something very similar. He sent a letter to House Republicans on January 5, noting that more than 400,000 Nevada residents have gained coverage as a result of the ACA, in large part because of Medicaid expansion. …
Nevada’s current total Medicaid spending is about $6.4 billion, but the state only pays $1.1 billion of that; the rest is picked up by the federal government (for the population that was already eligible for Medicaid pre-ACA, the state pays a higher percentage of the cost than they do for the newly eligible population; for people who are newly eligible for Medicaid under the ACA, the federal government paid 100 percent of the cost through 2016, and is now paying 95 percent of the cost).
If Medicaid expansion is repealed and replaced with something that cuts federal funding below what the state currently receives, there are concerns that people could lose coverage or benefits could be cut. House Republicans’ proposal to transition Medicaid to block grants or per-capita allotments would almost certainly result in reduced federal funding.

Nevada voted for Hillary Clinton in 2016, and chose a Democrat to replace retiring Sen. Harry Reid (D-Nev.). It’s a race that would be an uphill fight even without the health-care vote. If Heller does go along with the bill, his Democratic opponent will have a field day using the popular GOP governor’s words against Heller. One reason for Clinton’s victory was the successful mobilization of the culinary workers union. And that’s another problem for Heller. The Senate bill “erases a raft of tax increases that have helped offset the cost of Obamacare, but not the ‘Cadillac Tax’ that Heller and the powerful Culinary Union have vocally opposed.” The Nevada Independent explains: “That measure, which imposes a 40 percent excise tax on high-cost employer-sponsored health plans, would instead be delayed until 2026 under the Senate bill. Heller introduced legislation earlier this year to repeal the Cadillac Tax, which is currently scheduled to kick in in 2020. He said 1.3 million Nevadans would feel the pinch if it takes effect.” With the Cadillac Tax in the bill, a Heller vote in favor of the bill would put him crosswise with his constituents once again — and his own rhetoric.

Republicans’ desired intent to shift wealth from poorer to richer Americans also poses a serious problem for Heller. The Medicaid cuts and the reductions in the subsidies for the exchanges are bad enough, but when coupled with jumbo tax cuts for the rich, the bill would exacerbate Nevada’s growing income inequality problem.

Last September, the Las Vegas Review-Journal reported, “Nevada is one of just eight states that saw a slight increase in income inequality from 2014 to 2015, according to new census data that raise questions about the evenness of the state’s economic recovery.” The numbers may explain why Democrats have been winning statewide races in the state. It is true that “all groups in Nevada earned more in 2015 than they did in 2014. But the increases were higher at the top, with the top 20 percent of households seeing a 7.7 percent increase in average earnings, from $161,083 to $173,448, while the bottom 20 percent saw a hike of 2 percent, bringing their average annual earnings from $12,513 to $12,783.” Try to explain to Nevada constituents why a mammoth tax cut for the rich is a good idea.

Heller will be under pressure to get in line with party leadership and the White House. However, there is no member with a bigger need to claim to one of the two “no tickets,” the number of votes Senate Majority Leader Mitch McConnell can lose and still win passage of the bill. Heller had better put in his dibs early before others announce they can never vote for a bill this bad.