Here’s one unique, easy-to-grasp way to understand the continued gridlock among Senate Republicans on how to change the health-care industry: Each senator is trying to get the best deal for his or her state.
It’s a somewhat obvious observation, because that’s what happens in most congressional debates. But the last six weeks of Senate consideration of the Republican effort to overturn the Affordable Care Act has been somewhat lost in the weeds of Medicare regulations, the size and scope of tax credits and proposals to phase out benefits over a couple years or much longer.
That makes this process look a lot like what happens when, say, a big infrastructure bill is making its way through the Capitol, as lawmakers fight over regional funding formulas to try to maximize the benefits to their states.
“It all comes down to making sure you get what’s best for your own state,” said Sen. John Barrasso (R-Wy.), a key member of the GOP group overseeing the negotiations.
The most critical divide sits between Republicans from states that accepted the federal funding to expand Medicaid coverage to millions more Americans, and those from states that declined that expansion.
Many of the Republicans from non-Medicaid-expansion states are more conservative, and those from states that accepted the extra federal funding tend to be more moderate. But it’s not a purely ideological breakdown.
Take Sen. Lindsey O. Graham (R-S.C.), who started in Congress more than 22 years ago as a rabble-rousing conservative but has evolved into a leading dealmaker with Democrats. Yet on the Medicaid expansion issue, he’s with the hard-liners.
Graham has long supported allowing flexibility for states — for instance, allowing them to decline Medicaid expansion — so now he opposes fellow Republicans who want to revise the ACA but only with a generous exit ramp, in the form of a slow-moving phase-out, for their states and the Medicaid expansion dollars they receive.
Republicans like Graham take a purely parochial view: that a more costly phase-out of Medicaid expansion is a federal giveaway to states that made a bad decision to begin with when the ACA was first enacted.
Sen. Shelley Moore Capito (R-W.Va.) takes an equal and opposite parochial view. With 10 percent of her entire state’s population benefiting from the new Medicaid coverage, she is defending the interests of those constituents.
As Barrasso put it, it’s all about what is in the best interest of each senator’s home state.
“You have a number of members from states that expanded Medicaid, and you have a number of members from states that didn’t expand Medicaid. And the interests are different, of those states,” he said. “The interest is the same in that you want to protect your state.”
All of this is making the final weeks of negotiation a bit more difficult because neither side in this standoff is giving a full signal of their bottom line — what they’re willing to live with. Doing so gives away a leverage point, potentially leading to a little bit worse of a deal and thus endangering the entire negotiations.
The existing law expands eligibility for Medicaid coverage beyond its core target group of poor Americans to include anyone making up to 133 percent of the federal poverty level. It gives states 100 percent of the funding, with plans to ratchet down to 90 percent eventually. For many Republicans, the benefit presented a stark choice: say yes to a good deal that dramatically expands health coverage to the working poor, or say no to a federal entitlement that meddles in a state-run program.
The Republicans who saw Medicaid expansion as a noxious federal giveaway won the day in the ACA revision that emerged from the House earlier this year. That bill would begin eliminating Medicaid expansion in two years — eventually cutting Medicaid funding by roughly $880 billion over 10 years.
That detail of the Republican-written American Health Care Act is a big reason the Congressional Budget Office estimated that the bill would cause 23 million fewer Americans to have health insurance over 10 years. That number has stunned Republicans including Capito and Sen. Rob Portman (R-Ohio), another senator who hails from a state that took the Medicaid funding.
Some of these Republicans have been advocating for a seven-year phaseout of the Medicaid expansion. Also, Capito and Portman have been fierce advocates for guaranteed funding streams to help in the battle against the opioid epidemic that has particularly ravaged their states.
Republicans from non-Medicaid states view that long of a phaseout to be overly generous and the sort of timeline that will simply allow a new Congress in the next decade to try to prevent it from happening altogether.
All told there are 20 Republicans from states that accepted some version of the additional Medicaid funds, but they aren’t themselves a unified bloc. Some conservatives, including Sens. Tom Cotton (R-Ark.) and Patrick J. Toomey (R-Pa.), are searching for a middle-ground solution that meets their own ideological principles without too much pain for their constituents.
With just two votes to spare, Senate Majority Leader Mitch McConnell (R-Ky.) has to walk a tightrope in crafting a final deal on this, which Republicans hope could happen before the end of July.
There are other issues gripping these negotiations — how to determine the size of tax credits to help people buy private insurance, what type of coverage mandates from the ACA would apply under the new law, whether to eliminate federal funds for Planned Parenthood.
But nothing is quite as fundamental as the fight over the Medicaid money.
Barrasso, whose state declined the expansion, believes his governor and state legislature did a reasonable thing in declining the expanded federal funds.
“They were saying, ‘Look, we’ve got a big debt in this country and we realize the day is going to come when Washington isn’t able to meet all of these Obamacare promises,’” he said.
Their fear was that once Washington lost its ability to meet the funding levels, states would be forced to pick up the tab, bankrupting them in the process. Those states think they made the right call and shouldn’t have to pick up the tab for states like Ohio and West Virginia.
But the senators also don’t want to leave millions of people with no insurance.
For now, not enough Republicans have indicated that they’re willing to find a middle ground. Deep down, they have a bottom line, even if they’re not yet sharing it.
“I believe that each member knows,” Barrasso said. “And everyone doesn’t want exactly the same thing.”