(Peter Stevenson/The Washington Post)

The stark divide among Republicans on reshaping the nation’s health system came into full view over the past few days.

Formally unveiled Thursday, the Senate Republican plan came under immediate friendly fire from within Majority Leader Mitch McConnell’s GOP conference. The Kentucky Republican has just a few days to navigate the perilous path in trying to appease one bloc of holdouts without losing votes from another bloc.

It sets up a final frenzy of negotiation, as McConnell has determined he will finish with the legislation one way or another by the end of this month. If he’s not careful, the GOP leader could end up being lambasted by conservatives and liberals alike for cutting narrow deals to try to buy off votes from individual senators in a similar manner used for passing the Affordable Care Act.

McConnell can afford to lose only two of the 52 Republicans in the Senate, but as the week went on, he had many more holdouts than that.

The highest-profile defection, for now, came from Sen. Dean Heller (R-Nev.), who is usually a go-along-get-along acolyte to party leadership.

(Reuters)

But Heller faces the most difficult reelection next year of any Republican, and his state’s governor, Brian Sandoval (R), is extremely popular and remains a staunch supporter of the current funding structure for Medicaid’s expansion, which allowed nearly 300,000 Nevada residents to get health coverage.

“It’s simply not the answer,” he said Friday, with Sandoval at his side. He left some wiggle room to possibly support a rewritten draft but he made clear that his concerns went beyond just the proposed Better Care Reconciliation Act’s phaseout of federal support for the Medicaid expansion beginning in 2021. He questioned the plan’s protection for guaranteed coverage for critical conditions and other proposals.

“It’s going to be very difficult to get me to a yes,” Heller said.

His comments came after a quartet of Senate conservatives announced opposition to the legislation “as written,” shortly after McConnell released the plan Thursday. An additional handful of senators have expressed concerns about various provisions in the 142-page draft.

One of those conservatives, Sen. Mike Lee (R-Utah), received less attention than Heller but made clear just how far apart the two sides are in a nearly 900-word letter Friday to his constituents about the proposal. “No, the Senate healthcare bill released [Thursday] does not repeal Obamacare. It doesn’t even significantly reform American healthcare,” Lee wrote.

He went on to outline a demand that would in some ways undermine the very structure of the bill, allowing states to completely opt out of the law and create their own health-care systems. It’s the sort of demand that conservatives like but will be fiercely opposed by Democrats, as well as some Republicans, who fear that it would create too much chaos in the marketplace.

Republicans are acknowledging that they expect to know by Tuesday — Wednesday at the latest — whether they have the votes to pass the plan. If he can do it, McConnell then must spend the rest of the summer working with the House to see whether they can pass the Senate bill in whole, or negotiate a new compromise.

All of this makes the coming week’s initial vote — a simple parliamentary motion to begin debate — the critical test of support that will signal whether the legislation rises or falls.

“We take great care in doing the whip process, so we know before we go to the floor how the votes will turn out, so we’ll know that before that happens,” Sen. John Cornyn (R-Tex.), the majority whip, said Thursday.

Until now, McConnell has said very little in public, operating what could be called a strategy of political risk minimization.

His secretive process has been criticized loud and clear from Republicans and Democrats, with most of it directed at him. He does not mind taking media lashes if it keeps the heat focused on him and not his Republican colleagues. He did so last year when he absorbed most of the Democratic attack for refusing to consider the Supreme Court nomination of Judge Merrick Garland, while his Republican incumbents faced little criticism about it on the campaign trail.

The legislation will be in public view just a few days before the key votes, and by Friday the issue will be resolved, avoiding the long and politically debilitating negotiations that Democrats went through in 2009 and 2010.

But Democrats got a law passed, a really big one that went on to provide insurance to tens of millions of people, and they are now, after years of passively defending the ACA, fully engaged in promoting its benefits and trying to make Republicans look like mean-spirited accountants attempting to balance the books on the backs of the poor.

McConnell must decide if he wants to cut side deals to win or if a good-faith effort that comes up short is a better path forward politically.

So far the proposal includes only a modest $2 billion for a new funding stream to fight the opioid epidemic, an issue critical to a pair of Midwestern Republicans, Sens. Shelley Moore Capito (W.Va.) and Rob Portman (Ohio).

Once the Congressional Budget Office issues its report in the next few days about the proposal’s financial impact, McConnell will have a better sense of how many billions of dollars more in opioid funding could secure Portman and Capito’s votes.

Will Nevada get a specific carve-out on Medicaid funding to win over Heller?

That’s what McConnell’s nemesis, then-Senate Majority Leader Harry M. Reid (D-Nev.), did in 2009 to win over wavering Democrats to pass the ACA. Reid included a provision that provided full federal funding for the Medicaid expansion just to Nebraska, winning the vote of Sen. Ben Nelson (D-Neb.), who saw the initial proposal as an unfunded mandate.

The proposal was blasted as the “Cornhusker Kickback” and was eventually nixed. The final version of the law had 100 percent funding for all states for three years and then phased down to 90 percent federally subsidized funds for Medicaid’s expansion.

“This bill is a legislative train wreck of historic proportions,” McConnell said the day that Reid, Nelson and other Democrats unveiled the final package just before Christmas 2009.

Now, McConnell faces a similar dilemma.

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