Healthcare industry leaders and patient advocacy groups are facing a sobering reality as Republican senators weigh whether to pass their bill to repeal and replace the Affordable Care Act. Their staunch opposition to the repeal along with broad public disapproval may not be enough to convince lawmakers to kill the bill.
Several public opinion surveys last week found the Senate GOP's Better Care Reconciliation Act extremely unpopular, with weak support even among Republicans. In a USA Today/Suffolk University poll, just 12% of respondents supported the Senate bill while 53% said Congress should either leave the ACA alone or fix its problems while leaving its framework intact.
Maybe the GOP senators would pay a political price, maybe not, experts say. It depends on who they are more worried about angering — voters in their next re-election bid, or conservative activists and big-money donors from around the country who could defeat them in their GOP primary.
Hospital and physician groups widely oppose the GOP repeal legislation and are struggling to persuade Republican leaders to sharply revise their approach. They have stressed how the bill's coverage losses, weakening of consumer protections, and Medicaid cuts would harm patients and providers, even leading to increased mortality rates.
The bill's opponents have scored some success in organizing highly visible public opposition leading into this week's congressional holiday recess. Still, they feel they have gained limited traction with the Republican lawmakers themselves.
"The debate is over, the bill's opponents have won public opinion," said Robert Blendon, a professor of health policy and political analyst at the Harvard School of Public Health. "But that's not what Republican senators are talking about this weekend. They know the bill is unpopular. But they are relying on very motivated partisans to keep their seats, and that group will wants Obamacare repealed."
Sen. Shelley Moore Capito, R-W.V., one of 20 Republican senators representing a Medicaid expansion state, has expressed strong reservations about the Senate bill, which would phase out enhanced federal funding for expansion from 2021 to 2023. She and Sen. Rob Portman, R-Ohio, have demanded that Senate Majority Leader Mitch McConnell include $45 billion in funding for opioid addiction treatment, to replace Medicaid coverage for those who need such treatment.
But if Capito fought to defend the Medicaid expansion, she could face a challenger funded by out-of-state conservative groups in her 2020 re-election bid, said Simon Haeder, an assistant professor of political science at West Virginia University. She already saw how big, out-of-state money helped swing last fall's state attorney general election.
"She'd suffer more for defending Medicaid expansion than for reversing her position," he said.
Sen. Dean Heller, R-Nev., who faces a tough re-election contest next year, got a taste of this last month when a White House-backed outside group launched a $1 million advertising attack against him for coming out against the current version of the Senate repeal bill. The group backed off under pressure from McConnell. After that, a chastened Heller announced he was open to further negotiation on the bill.
In deciding how to vote on the repeal legislation, senators like Heller and Portman are weighing the possibility of punishment from voters in their next re-elections against the near certainty that they'll face a well-funded, very conservative primary challenger.
They're "hemming and hawing, but they'll face the choice of the end of their political career, not from November voters but from Republican primary voters, activists and donors, who will consider a no vote a betrayal," said Lawrence Jacobs, an expert on healthcare politics at University of Minnesota.
Big conservative donors like the billionaire Koch brothers have made it clear they will punish GOP lawmakers financially if they don't come through on repealing Obamacare and cutting taxes.
"If they don't make good on these promises … there are going to be consequences," Sean Lansing, chief operating officer for the Koch network's political arm, Americans for Prosperity, told the Associated Press at the Koch brothers' donor retreat last month in Colorado Springs.
Attending that conservative retreat was Sen. Cory Gardner, R-Colo., whose state expanded Medicaid and who has voiced concerns about the Senate repeal bill. Gardner said he was working on revisions to the Medicaid part of the Senate bill.
"We've reiterated to him over several months the value of Colorado's Medicaid expansion in terms of reducing ER visits," said Steve Summer, CEO of the Colorado Hospital Association, who also knows West Virginia Sen. Capito well from his years working in that state. "She and Sen. Gardner are very good advocates for their constituents. I'm keeping an open mind on whether they're able to craft some kind of solution."
Political observers say the wavering GOP senators and congressmen may want to think beyond their next primary about the political repercussions of passing the Senate repeal bill. The Congressional Budget Office projected it would lead to 15 million more uninsured people next year and hike individual-market premiums by 20%. Much will depend on whether voters aggrieved by the legislation turn out in the November 2018 congressional elections.
"The ripple effects of people losing coverage and safety net hospitals getting hit hard will be felt as early as next year," Jacobs predicted. "If Republicans pass repeal, they'll be running for their storm cellars and just trying to survive past the next election."
