Healthcare wish lists: What moderates, conservatives want

Divisions between moderate and conservative Senate Republicans on how to repeal ObamaCare appear to be widening.  

Senators from the two camps have vastly different ideas about what needs to be changed in the repeal-and-replace legislation, and it’s unclear what kind of compromise GOP leadership can present that would satisfy both sides.

Conservatives want the bill to end as many ObamaCare regulations and taxes as possible, while the moderates want more federal spending on Medicaid. Lacking a clear path forward, Majority Leader Mitch McConnell (R-Ky.) delayed a vote on the bill until after the July Fourth recess.

{mosads}With a slim 52-48 majority in the upper chamber, GOP leaders can only afford to lose two votes and still pass healthcare legislation, assuming Vice President Pence breaks a tie. Senate leaders want to finish negotiations by the end of this week, but there’s skepticism that timeline can be met.

With that in mind, here’s what the two sides are asking for.

Conservatives

Conservatives in the Senate, led by Sen. Ted Cruz (R-Texas), believe they’ve gained leverage in recent days, and their demands have grown louder.

They think the legislation as written doesn’t go far enough to repeal ObamaCare or lower premiums. They also say the bill authorizes too much federal spending on subsidies to help low-income people afford health insurance.  

The easiest way to bring conservatives on board would be to repeal all of ObamaCare’s insurance regulations. Sens. Mike Lee (R-Utah), Ron Johnson (R-Wis.) and Cruz think gutting those rules is the quickest way to bring down premiums.

“If we were to repeal all of the market reforms, utilize high-risk pools to make sure people with pre-existing conditions were covered, we could literally drive down the gross premiums for every American,” Johnson said.  

Sen. Rand Paul (R-Ky.) has also sided with the conservatives on repealing the regulations, but on Wednesday released his own wish list, separate from what Cruz, Lee and Johnson have been asking for.

Paul is also asking that McConnell drop a provision added earlier this week that would require individuals who miss an insurance payment to wait six months before being able to sign back up for insurance. He also called for leadership to remove a provision that appropriates a “stability fund” to shore up the ObamaCare exchanges.   

Repealing all the ObamaCare rules would include getting rid of the regulations that prevent insurers from discriminating against people with pre-existing conditions. The Senate bill would let states waive some of those protections, but many of ObamaCare’s insurance rules would remain.

If leaders accede to the conservative demands, they risk inviting the kind of public backlash that plagued the House GOP bill. They also risk losing the support of moderates like Sen. Bill Cassidy (R-La.).

Moderates

The most vocal GOP moderate on this issue is Sen. Susan Collins (Maine). Collins has expressed concerns over the legislation early and often. After the vote was delayed, she said she wasn’t sure the measure could be changed to win her over.

Collins said she has “so many fundamental problems with the bill that have been confirmed by the [Congressional Budget Office] report that it’s difficult for me to see how any tinkering is going to satisfy my fundamental and deep concerns about the impact of the bill.”

Moderates are also fretting about the bill’s impact on Medicaid. The legislation would roll back ObamaCare’s Medicaid expansion and put a cap on federal funding to states for the first time.

GOP senators from expansion states such as Rob Portman (Ohio) and Shelley Moore Capito (W.Va.) have pushed for a seven-year phaseout of the Medicaid expansion, rather than the three years currently in the bill.

GOP leadership could also consider making the bill’s tax credits more generous. The Congressional Budget Office projected the legislation would disproportionately benefit younger, healthier people.

Capito said she wants “more robust help for older and less affluent rural people.”

But spending more on subsidies is exactly the opposite of what conservatives want.  

Capito and Portman are also pushing for $45 billion over 10 years to combat the opioid epidemic in their states. But even if McConnell bolstered the opioid funding, Capito suggested it probably wouldn’t be enough to secure her support.

“More opioid funding would be very good and very beneficial, but the core for me is the Medicaid provision,” Capito said.