Can Republicans Do the Impossible on Health Care?

Probably not but maybe.

Senate Majority Leader Mitch McConnell looks on during a news conference about the health care bill on Capitol Hill in Washington on Tuesday.

Aaron P. Bernstein/Reuters

Senate Republicans are going to vote on a health care bill next week. If you think you’re confused about which bill that will be, you should hear how confused Senate Republicans are.

No one knows whether the bill that leaders are pursuing is the Obamacare repeal-only bill or the revived repeal-and-replace bill (that had been left for dead earlier this week). The consensus favorite at any given time is fluid. Senate leaders start working one particular bill and realize that the votes aren’t there for it. Then they consider the other bill, realize the votes aren’t there for that either, and return to consider the first one. Forever.


“I do have a sense that it’s changing every few hours,” Wisconsin Sen. Ron Johnson said Thursday morning. “I’ll confirm that.”


Thanks, Ron.

There is currently no path to passing either of these bills—especially with Arizona Sen. John McCain, who’s been diagnosed with brain cancer, out indefinitely. And Senate Majority Leader Mitch McConnell first has to persuade enough of his members to vote to proceed to debate. But that doesn’t mean you should celebrate if you’re not a fan of Republican health care efforts. Republicans have no path but a lot of resolve. It will require a miracle to pass one of these bills. But strange things can happen when the majority party insists on it.


Here are the hurdles:

The Motion to Proceed

Senators first have to vote to open debate on the bill, or “get on the bill,” as it’s called in annoying congressional lingo. This will be the easiest part, and it will be nearly impossible.

Republicans need 50 votes on the motion to proceed to debate, with Vice President Mike Pence serving as a tiebreaker. With McCain out, Republicans have 51 total senators voting. Maine Sen. Susan Collins does not seem to be softening whatsoever in her opposition to either the Better Care Reconciliation Act, the repeal-only bill, or whatever other wackadoo health-related schemes a group of GOP-only senators comes up with in the next few days. So leaders will need to get every other senator’s vote.


As I count it, though, there are not any other hard noes on the motion to proceed at the moment. “At the moment” should be stressed. McConnell may be masking the true number of hard noes by keeping the ball in the air: Senators such as West Virginia’s Shelley Moore Capito, Nevada’s Dean Heller, and Alaska’s Lisa Murkowski, at least, eventually will want to know the plan before voting to proceed. (In the most delightful quote of the day, a reporter asked Senate Majority Whip John Cornyn on Thursday: Don’t some senators want to know the plan before they vote to proceed? “That’s not a luxury we can afford,” he replied.)

McConnell got one piece of good news on Thursday afternoon: Kentucky Sen. Rand Paul said that he would vote to open debate if the repeal-only bill is called up for a vote as the first amendment.


If McConnell can find a way to keep all senators onboard, save Collins, through a mix of payoffs and pledges, they can get on the bill and begin the open amendment process.


If you want Paul and Utah Sen. Mike Lee to vote to proceed, you’ve got to offer them a vote on that sweet, sweet repeal-only legislation. Though one influential senator, Tennessee Sen. Bob Corker, came out in favor of this approach on Thursday, it still has, at best, 47 votes. This is taking into account those who have publicly opposed the approach—Capito, Collins, Murkowski, and Ohio Sen. Rob Portman. The true number could be much lower. Tennessee Sen. Lamar Alexander speculated Wednesday that there might not even be 40 votes for a repeal-only bill. It is very difficult to see this bill, and all the chaos it would bring with it, gaining the momentum to reach 50 votes. But the conservatives want it to have a chance.



Senators are still trying to make the BCRA happen. I have been writing for weeks that the broad outline of an agreement, if there is going to be one, involves giving the conservatives deregulatory changes while softening the Medicaid cuts for the moderates. That is still true.

Though Texas Sen. Ted Cruz got his amendment, which would allow insurers to sell unregulated plans under certain conditions, it did not go quite far enough for Lee. Senate leaders are hoping that the favorable, though highly suspect, new scoring of the Cruz amendment from Donald Trump’s Health and Human Services Department gets Lee on board.

Though leaders didn’t change anything about the Medicaid portion of the bill in the version they released last week, they may be coming around. The Hill reported Wednesday night that leaders are considering offering up to $200 billion to help low-income people who gained insurance under Obamacare’s Medicaid expansion obtain private coverage. The trick for McConnell will be to prove to the senators concerned about Medicaid cuts that this is enough money without losing the conservatives (or rank and file) who are getting seriously uncomfortable with the amount of money being thrown around.


And this is where we hit the dead end.

Neither Paul nor Collins, at the very least, has shown any interest in voting for the BCRA, and with McCain out, leaders can only lose one vote. McConnell could try to tell Paul that he will only give him a vote on the repeal-only bill if, once that fails, Paul agrees to vote for the BCRA. There’s no indication McConnell has asked him that or that Paul would even agree to it. Further, Paul was uncomfortable with the amount of spending in the BCRA when it surpassed zero dollars. If leaders offer moderates another $200 billion, Paul may well have a heart attack.

The votes right now aren’t there for anything, including the motion to proceed. Even if senators get past that procedural hurdle, they can’t pass either of the bills they’re considering.

But the fact that the Republican Senate majority is willing to make such fools of themselves still trying to make this happen should give anyone pause about writing the effort off. It is their signature legislative effort, and they will be a laughingstock if they fail. Miracles, like the separation of millions of low-income older people from their health coverage, can happen.