Senate health care bill: 9 Republican senators whose votes will be key

WASHINGTON — Senate Republicans need 51 votes to pass their bill to repeal and replace Obamacare.

Because no Democrats are expected to vote to repeal the Affordable Care Act — they spent nearly all of Thursday after the GOP bill's release railing against it on the Senate floor — Republicans can't lose more than two of their own members for the bill to pass. (The GOP has a narrow 52-48 majority in the Senate, but Vice President Pence can be brought in to break ties.)

That slim margin means a difficult job for Senate Majority Leader Mitch McConnell, R-Ky., who must try to convince the various factions of his party to come together and back legislation that was written pretty much in secret and is supposed to be voted on just one week after its release.

Here are nine senators USA TODAY is watching to see whether they break with their party:

The conservatives

Sens. Rand Paul, R-Ky., Mike Lee, R-Utah, Ted Cruz, R-Texas and Ron Johnson, R-Wis., were out the gate just a couple hours after the bill’s release with a joint statement that said they weren’t ready to vote for the bill as-is, but “we are open to negotiation and obtaining more information before it is brought to the floor.”

“It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs,” the group wrote.

Paul told reporters that the goal of releasing the statement as a bloc was to get the attention of Republican leadership: “Now that it is known that there are not 50 votes for this, I hope that those who ... have written the bill will negotiate with us.”

Paul said it was his “hope” that the four senators would keep their votes together as a bloc. But he acknowledged that the only agreement the group had made so far was to issue Thursday’s joint statement.

The anti-opioid crusaders

Sens. Rob Portman, R-Ohio, and Shelley Moore Capito, R-W.Va., are concerned the GOP plan would undermine efforts to curb the opioid epidemic, which has taken a deadly toll on their respective states. The biggest sticking point: Medicaid expansion.

Ohio and West Virginia — along with 30 other jurisdictions — expanded Medicaid enrollments under the Affordable Care Act. That expansion has dramatically increased access to addiction treatment for low-income childless adults — a population heavily affected by the opioid crisis.

Leading up to Thursday’s bill unveiling, Portman and Capito worked in quietly and in concert to try to soften the GOP legislation — with mixed results. They sought a seven-year phase-out of the extra federal Medicaid expansion funding, urging GOP leaders to gradually ratchet down that money through 2027. They also pushed for an extra $45 billion over 10 years in funding for opioid treatment as a cushion for those who might lose access to treatment.

GOP leaders included a four-year phase-out of the Medicaid expansion funds and $2 billion for one year of extra opioid money. Portman signaled that might not be enough to win him over, and Capito seemed lukewarm as well.

The Planned Parenthood defenders

The Senate bill would cut Medicaid funding from Planned Parenthood for one year, and prevent clients from using federal money for services at the group's clinics, but Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska, have defended the women's health organization and said it shouldn't lose government funding.

"I do not like the provision that eliminates federal funding for Planned Parenthood," Collins told reporters Thursday. "It makes no sense to single out Planned Parenthood from all the Medicaid providers and say that it can’t be a Medicaid provider."

"There’s absolutely no need for that," Collins said, pointing to the Hyde Amendment, legislative language that already prohibits federal funds from being used for abortions.

Murkowski, like Collins, is a supporter of Planned Parenthood. In a speech to the Alaska state legislature in February, she vowed not to vote for any Obamacare replacement bill that would defund the organization.

"I, for one, do not believe that Planned Parenthood has any place in our deliberations on the Affordable Care Act," she said in her address to state lawmakers. "Taxpayer dollars should not be used to pay for abortions, but I will not vote to deny Alaskans access to the health services that Planned Parenthood provides."

Both senators have also been vocal about providing a softer landing for people who had been on Medicaid.

"It’s no secret that health care needs to be reformed, but it needs to be done right," Murkowski said in a statement Thursday.

"I can’t support a bill that's going to greatly increase premiums for older Americans or out-of-pocket costs for those who aren’t quite old enough for Medicare yet," Collins said on MSNBC Thursday night. "I cannot support a bill that's going to result in tens of millions of people losing their health insurance. And I cannot support a bill that is going to make such deep cuts in Medicaid, It isn’t any one factor ... But it is all of those factors put together that'll influence my decision. 

The most vulnerable senator

Nevada Sen. Dean Heller is considered the most vulnerable Republican senator up for re-election in 2018. He is the only GOP senator running for re-election in a state won by Hillary Clinton in the 2016 election, and the state also expanded Medicaid under Obamacare — both of which put Heller in a tough position. In a statement Thursday Heller said “I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid.”

“I have made clear that I want to make sure the rug is not pulled out from under Nevada or the more than 200,000 Nevadans who received insurance for the first time under Medicaid expansion,” Heller said.

At a press conference Friday with Brian Sandoval, Nevada's Republican governor, Heller said he will not vote for the bill. "I'm announcing today that in this form, I simply will not support it," Heller said.

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