Senate Republicans compare health care negotiations to hitting a ‘moving target’

The operative word is “if.”

There are at least five major sticking points for Senate Republicans. Some of those grievances are certain to be addressed by the leadership on Friday, but it is not clear whether the changes will be sufficient for members who are now holding out for a better deal.

As Trump told Fox News last week, “It’s a very complicated situation … you do something that’s good for one group but bad for another. It’s a very, very narrow path.”

Rallying support for the plan to repeal and replace the Affordable Care Act, or Obamacare, has been further complicated by its secrecy and the process, which is “just like shooting at a moving target,” as Sen. Chuck Grassley (R-Iowa) put it.

For example, Sen. Rand Paul of Kentucky wants a plan that will “look more like a repeal of Obamacare.” The current plan maintains many of the cost-sharing subsidies under Obamacare to guarantee insurers can provide coverage to low-income and middle-class Americans. The bill also includes a multi-billion dollar stabilization fund to provide certainty for the insurance market as the change in law goes into effect.

Other conservatives and even President Trump himself campaigned on the promise to repeal and replace Obamacare, but Paul and a number of House Republicans see the current plan as “Obamacare lite.”

Others, like Sen. Dean Heller of Nevada,  are concerned about the roll-back of Medicaid expansion, which could result in $772 billion in cuts by 2026. Heller is in a tenuous position. He is up for reelection in 2018 in a state that expanded Medicaid substantially under Obamacare. Nevada experienced one of the most dramatic declines in the number of uninsured under the Affordable Care Act.

Sen. Shelley Moore Capito of West Virginia cited the cuts to Medicaid as her chief reason for not supporting the plan.

“West Virginia has the largest Medicaid population in the country,” Capito said in a press release. “As drafted, this bill will not ensure access to affordable health care in West Virginia, does not do enough to combat the opioid epidemic that is devastating my state, cuts traditional Medicaid too deeply, and harms rural health care providers.”

Others share the concern over the impact of letting states opt out of essential health benefits. Those ten benefits established under the Affordable Care Act required insurers, including Medicare and Medicaid, to cover emergency services, prescriptions, maternity care, pediatric care, and also mental health coverage, which includes treatment for drug addiction.

Sen. Rob Portman of Ohio and others in states with high rates of opioid abuse and death are concerned that the cuts in Medicaid will hit his state particularly hard.

The reductions in Medicaid are “particularly problematic” for Ohio, he told reporters, “because of the opioid crisis and the degree to which people depend on Medicaid for their treatment.”

One possible fix is a $45 billion opioid addiction fund, which Portman said would be “progress,” adding, “there’s still a lot of other moving parts.” Other representatives in states facing the epidemic worry that $45 billion will not be enough to help the tens of millions of Americans battling addiction.

One of the top selling points of the Senate’s Better Care Reconciliation Act is that it repeals almost all of the Obamacare taxes. That includes a 3.8 percent tax on net investment income, which affects those earning upwards of $250,000 per year.

According to the CBO, repealing the Obamacare taxes will mean the federal government will lose out on $701 billion in revenue through 2026. But those losses are offset by more than $1 trillion in cuts, a large portion coming from reductions in Medicaid.

That’s a problem for senators like Susan Collins of Maine, Bob Corker of Tennessee and Mike Rounds of South Dakota who said they could not support repealing the tax if it meant low-income Americans would have worse or less affordable coverage.

“There may be some other method … of dealing with this that doesn’t involve repealing [the investment tax],” Corker told reporters. But leaving it as is, he said, is “not a sustainable proposition.”

Sen. Mike Rounds of South Dakota is open to keeping the tax, because it will mean $172 billion over ten years. That money would be available “to resolve other issues” raised by senators who currently oppose the bill.

From the get-go, the passage of the Republican’s bill to repeal and replace Obamacare was not going to involve Democrats. That’s why the bill has been teed up to be passed through reconciliation, a procedure that allows the bill to pass with only a simply 51-vote majority. But that process has complications of its own, particularly once the bill gets to the floor and faces “virtually unlimited amendments.”

The end zone is still weeks away, said Sen. Lamar Alexander (Tenn.) chairman of the health committee, who explained how the process will move forward.

A number of the ideas put forward this week by senators to improve the health bill and address members’ objections will be submitted by the end of the week to the Congressional Budget Office. Again, it’s not clear which proposal will make McConnell’s cut. After the CBO produces an estimate on the changes, the Senate leadership will go back to the drawing board to produce another draft, which it will make public.

“Then it will go to the floor for virtually unlimited amendments,” Alexander explained.

That means even more moving parts.

While Donald Trump downplayed the importance of getting a deal done, it will be hard for the Republican Party to justify keeping the status quo of Obamacare after seven years of campaigning against it.

But even on the Democratic side, there is a sense that the GOP will not easily accept defeat.

“We all know McConnell doesn’t give,” Sen. Sherrod Brown (D-Ohio) said, noting that the Republicans have sought to roll-back government programs like Medicaid and Medicare for at least thirty years. “They think this is the most titanic battle in decades … That’s why they’re not going to give up easily.”