with Paulina Firozi


Whether the Senate will be able to pass its Obamacare overhaul is coming down to just three still-skeptical Republican moderates: Dean Heller of Nevada, Shelley Moore Capito of West Virginia and Rob Portman of Ohio. Republican leaders and the Trump administration are trying to sell it to them this way: Don’t worry about the bill’s steep Medicaid cuts or how many people are projected to lose coverag -- we’ll make up the difference by flexing big executive muscles.

A few hours after releasing a revamped version of his health-care bill yesterday morning – with the hopes of attracting the 50 votes needed to pass it next week, Senate Majority Leader Mitch McConnell (R-Ky.) huddled in his office with the Heller/Capito/Portman trio, plus Alaska’s Lisa Murkowski.

All four are from states that expanded Medicaid under the Affordable Care Act to cover able-bodied, childless adults. They’re deeply hesitant to support the bill because it would phase out the extra federal funding for Medicaid expansion and enact deeper, underlying cuts to the program overall.

Also at the meeting: Seema Verma, administrator of the Centers for Medicare and Medicaid Services, whose agency would be central to carrying out the GOP plan. In a presentation that involved a flow chart, she promised the senators to do everything possible to minimize the number of uninsured by giving states maximum flexibility in how they could use some of the money from the bill’s $182 billion state stabilization fund.

Nearly 15 million Americans would lose their Medicaid coverage by 2026 under the Senate bill, according to the Congressional Budget Office. Verma sought to minimize that outlook, saying states could use the stabilization funding to heavily subsidize private coverage for these Americans — even though the size of the fund does not come close to the bill’s $772 billion in cuts to the program over the next decade.

The Trump administration certainly can give states wide leeway in how they use the stabilization money. But the fact remains that the GOP health-care bill repeals taxes and still saves money by dramatically reducing the federal contribution to Medicaid and whittling down Obamacare’s insurance subsidies. For conservatives, this isn’t such a bad deal. They’re excited about lowering the federal government’s Medicaid burden.

But at the end of the day, less money equals less money. So it’s a stretch – a big, big stretch – to argue that the same level of government resources will be available to low-income Americans under the Senate bill.

Murkowski, while wary of the legislation, now isn’t likely to be as big of a problem for McConnell, since he added in a provision sending hundreds of millions of extra dollars to Alaska through a formula to assist states with extra-high premiums.

But whether the Heller/Capito/Portman crowd will buy the Trump administration’s argument – and supply McConnell with enough votes to pass the legislation next week -- remains to be seen. They said yesterday that they’re still reviewing the measure. Portman said he was not yet willing to vote yes to move the bill to the floor.

“I’m in the same position I’ve been in, looking at the language and looking forward to the analysis,” Portman told my colleagues Sean Sullivan, Kelsey Snell and Juliet Eilperin.

From Sean:

From NBC's Leigh Ann Caldwell: 

Capito said she's still reviewing the bill:

McConnell has to entice every single one of them because two Republicans have walked off the field at this point. Sens. Rand Paul of Kentucky and Susan Collins of Maine both said yesterday they’ll vote against even starting debate next week on the measure. 

Fifty members remain – but if any more bolt, Republicans will surrender -- for now at least -- their long-stated goal of repealing and replacing Obamacare.

Moderates are the problem because McConnell opted to maintain most of the bill’s big cuts to federal Medicaid spending, only adding in incremental changes designed to appeal to the pragmatists. The new bill includes $45 billion for substance abuse treatment, retains the ACA’s net investment tax on the wealthiest Americans and providers more Medicaid dollars for hospitals serving a higher share of the low-income.

Politico's Jen Haberkorn says Heller is still very undecided:

But McConnell has this going for him. He basically bagged conservatives yesterday by including Sen. Ted Cruz’s (R-Tex.) amendment allowing broad opt-outs from insurer regulations. Under it, insurers could sell cheaper, stripped down insurance plans off the marketplaces as long as they offered one, ACA-compliant plan on the marketplaces.

This would result in less-expensive but leaner insurance for healthier Americans, which is a key goal that Cruz, Lee and conservative groups including the Heritage Foundation, Club for Growth and FreedomWorks had rallied around.

Paul’s out, but two of the other conservatives who had previously opposed the bill are now “yes” votes: Cruz and Ron Johnson (R-Wis.). A fourth, Mike Lee of Utah, says he’s still a holdout, but it would be surprising if he ultimately split with Cruz.

“The new Senate health care bill is substantially different from the version released last month, and it is unclear to me whether it has improved,” Lee said in a statement. “I will need time to study the new version and speak with experts about whether it does enough to lower health insurance premiums for middle class families.”

The Post's Dave Weigel spoke with Johnson:

Here's what Johnson told Bloomberg's Sahil Kapur:

Want to keep score at home? Follow along with The Post's crack whip count on where Senate Republicans stand on the revised health-care plan.


AHH: The trust fund that pays Medicare's hospital expenses will run out of money in 2029 -- a year later than was projected last year -- while the Social Security program will remain solvent until 2034, a projection unchanged from last year. The annual trustees report with the projections provides an annual glimpse into the federal government's two biggest entitlement programs, which comprise 42 percent of federal program spending.

The trustees noted that the growth in national health spending in the United States has slowed in recent years, which helped keep the Medicare program solvent for an additional year longer and helped avoid activating the Independent Payment Advisory Board, a 15-member board that is tasked with proposing Medicare cuts if spending grows faster than a target rate, The Post's Carolyn Y. Johnson reports. But all is not rosy.

"The trustees said that both Medicare and Social Security face long-term challenges," Carolyn writes. "They exhorted lawmakers to act soon to implement new policies to shore up the programs, while there is still time for the public -- particularly vulnerable populations -- to prepare."

OOF: Sen. Cory Gardner (R-Colo.) faces one of the tougher political predicaments of any Republican deciding how to vote on the health-care bill, my colleague Paul Kane writes. Gardner leads the campaign committee responsible for protecting and expanding the GOP majority, making him a close ally to McConnell and upping expectations that he falls in line.

--But he also has home-state interests that make this one of the more difficult roll calls of his career. Colorado’s popular Democratic governor, John Hickenlooper, not only accepted the ACA’s Medicaid expansion, but has also become a leading spokesman against the GOP effort to overturn Obamacare.

"All of it makes Gardner’s a classic case of the inside-outside dilemma," Paul writes. "He can vote for the bill and earn points in Washington, or he can cast a vote that would likely be an easier sell to voters back home.

OUCH: Maybe we should label this "LOL" instead. Speaking with reporters on the way to Paris this week, Trump said "the only thing more difficult than peace between Israel and Palestine is health care." While foreign policy experts might find this statement downright offensive, The Health 202 thinks truer words were never spoken.


--Trump's in Paris, but he's been watching the Senate health-care machinations from afar. He went on a mini-tweetstorm about it this morning:

--Trump’s budget proposal got a score from the CBO yesterday, showing it would not add to economic growth or eliminate the deficit in coming years. The score casts doubt on a plan the White House has touted as central to achieving the president’s domestic agenda, The Post's Damian Paletta, Ana Swanson and Max Ehrenfreund write.

"The CBO projected that the economy would grow at only 1.9 percent under the White House’s plan — far below the 3 percent goal the administration continued to outline as recently as Thursday," my colleagues write. "It also warned that contrary to White House claims that deep cuts to the safety net in the budget would lead to a financial surplus in a decade, the deficit would actually be $720 billion."

"The report was one of several big questions that emerged Thursday about whether Trump would be able to deliver on the central promises of his populist agenda for governing," they continue. "He had pledged to replace President Barack Obama’s Affordable Care Act with a better policy that guaranteed 'insurance for everybody.' But Republican Senate leaders on Thursday were advancing a proposal — its fate uncertain — that would still swell the nation’s ranks of the uninsured by tens of millions."


--Even as McConnell negotiated with individual members yesterday, the outlook for his bill got even more complicated when Sens. Bill Cassidy (R-La.) and Lindsey O. Graham (R-S.C.) debuted an alternative proposal. In a joint interview with CNN, the two said they would take the billions of dollars the federal government now receives in taxes under the ACA and direct that revenue to the states.

The plan did not appear to be gaining traction — Graham said he would vote to start debate on McConnell’s bill — but its introduction underscored the extent to which a growing number of GOP senators have started looking beyond the current effort, with diminishing confidence that it will prevail. Their surprise announcement came just before Senate GOP leaders released their revised health-care proposal.

Some more good reads from The Post and beyond:



  • The American Enterprise Institute is holding an event on Medicare in the Trump era.

Why did two GOP senators just introduce a competing health-care plan?

The Fix's Aaron Blake explains the politics behind the two dueling proposals. (Meg Kelly/The Washington Post)

Senate Majority Leader Mitch McConnell (R-Ky.) jabs Democrats while introducing new version of Senate health-care bill:


Introducing new provisions to the Senate health-care bill July 13, Senate Majority Leader Mitch McConnell (R-Ky.) said he expects "Obamacare defenders" to launch the "same tired and predictable attacks," on this new version of the bill, saying "It hardly matters what the draft says." (U.S. Senate)

Senate Republicans unveil competing health-care proposals: 

Senate Majority Leader Mitch McConnell unveiled a revised GOP health-care proposal on July 13 — but two other Republican senators released a competing plan. Her (Peter Stevenson/The Washington Post)

Sen. Charles E. Schumer (D-N.Y.) tears apart the Cruz amendment:

Senate Minority Leader Charles E. Schumer (D-N.Y.) launched an attack on the Senate Republican health-care bill immediately after it was introduced July 13, saying it is worse than before because it includes something like the Cruz amendment. (U.S. Senate)

House Minority Leader Nancy Pelosi (D-Calif.) criticizes the bill: 

House Minority Leader Nancy Pelosi criticized the GOP Senate health- care bill unveiled on July 13. (Reuters)

Watch Stephen Colbert recreate White House counselor Kellyanne Conway's "fun with words":