Senate GOP holdouts split into rival camps on ACA overhaul

The House bill would phase out that expansion starting in 2020 — part of an larger plan to cut Medicaid by $880 billion and taxes by $883 billion over a decade.

Some conservatives have demanded an earlier phaseout, something that could make it even harder for those senators to support the measure. It also makes potential swing voters out of senators from Arkansas, Nevada, Alaska, Colorado, Ohio and Louisiana — all states that expanded Medicaid.

Other holdouts

Bill Cassidy of Louisiana says he wants to radically reshape the House bill so that it covers more people, not the 24 million fewer estimated by the Congressional Budget Office.

"Society is going to pay for health care whether it is through insurance or not," he said last week. "Society will pay for it either through cost-shifting to the privately ensured or it will pay for it through enhanced disproportionate payments" to hospitals that treat indigent patients.

A doctor who worked for decades in a charity hospital, Cassidy crafted a bill with Collins that would keep most of the Affordable Care Act's taxes and allow states to choose between keeping Obamacare largely as is or transition to a new system with more flexibility.

Cassidy has spoken emotionally and in depth about the importance of coverage, saying society pays one way or another when people go to the emergency room because they don't have insurance, and criticizes the House bill for failing to meet President Trump's campaign promise of insuring more people at a lower cost.

And then there's Tom Cotton of Arkansas, normally a staunch conservative, who has emerged as a surprising wild card. He has warned House Republicans to go back to the drawing board because he thinks the bill could endanger the House majority and won't pass the Senate.

Notably, Arkansas also has an enormous Medicaid expansion population and is one of the poorer states in the union.

State of play

The two toughest votes to get on each side may be Collins and Paul. Paul blitzed the bill even before it was released, when it was being drafted in secret and kept under lock and key, and he has shown repeatedly in the past he's willing to be the only one in his party to oppose something on principle.

And it's hard to square the House bill with the rhetoric Collins has used to describe it. She's noted her state skews old, and the House bill hits older Americans now on Obamacare with premium hikes as high as 759 percent, according to the CBO, to pay for skimpier insurance. She told a local paper last week she couldn't vote for the House bill as is.

If Paul and Collins both end up voting no, GOP leaders would have to win over everyone else. Leadership hopes could hinge on convincing Cruz and Cassidy to vote for the bill after getting a chance to amend the health bill, even if their amendments ultimately are defeated.

It's also not clear how much of the House bill will be able to withstand the so-called Byrd rule, which prohibits provisions that aren't principally budget related. That would potentially require parts of the bill to be rewritten on the Senate side anyway, and then sent back to the House. Final House passage also would be needed if broader amendments pass in the Senate.

Despite the obstacles, Senate Republican leaders say they're still optimistic they can pass a bill — with Majority Leader Mitch McConnell noting last week that changes could be made during a "vote-a-rama" on amendments. He hopes to pass it before the April recess, bypassing Senate committees and going straight to the floor.

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