Senators McCain, Graham, Cassidy and Johnson Discuss Health Care Reform
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Republicans say they're gaining momentum in yet another effort to pass a health care bill in the Senate, but they admit they're in the same challenging spot they were each time before.

The math has not changed.

When Independent Journal Review asked Sen. Bill Cassidy (R-La.) if his bill has better chances for passage than previous attempts, he was silent.

Sen. Chuck Grassley (R-Iowa) conceded that Republicans face the same problem they faced before: having enough votes.

“There's three Republicans who voted against the other one,” he said. “Assuming we don't lose any, then it's kinda ... has any one of them changed their mind?”

Republicans can only lose two senators on a health care bill and still pass it with the help of a tie-breaking vote from Vice President Mike Pence. If Majority Leader Mitch McConnell (R-Ky.) loses three members of his caucus, the bill is dead.

That's what happened this summer, when Sens. John McCain (R-Ariz.), Lisa Murkowski (R-Alaska), and Susan Collins (R-Maine) teamed up to vote against the GOP's last-ditch “skinny repeal” effort and effectively killed the stalling legislative effort.

Or so everyone thought. Capitol Hill turned attention back to health care Monday after a Politico report indicated Republican leaders started seeking support for Cassidy and South Carolina Sen. Lindsey Graham's bill. If enacted, it would block-grant funding for states. It would increase states' flexibility on consumer protections, potentially hurting sick people's ability to afford health insurance. It would also pare down the Affordable Care Act's Medicaid expansion.

One Republican vote is already gone.

Sen. Rand Paul (R-Ky.) is staunchly opposed to the Graham-Cassidy repeal because he believes it doesn't repeal enough of the ACA's taxes and shouldn't be entertained as an option by conservative lawmakers. His no vote, for now, is clear:

Paul voted for the skinny repeal bill, but that was an entirely different situation — lawmakers were promised the skinny repeal wouldn't become law and would undergo substantial changes in a conference committee after passage.

Paul assured reporters throughout the afternoon and evening that his opposition to the Graham-Cassidy bill was not up for debate, short of massive changes to the bill.

And that means if Republican leaders lose two more votes, this effort is also over.

They only have until the end of the month to pass a health care bill out of the Senate using the budget reconciliation process, which allows for passage on a simple majority vote without needing help from Democrats. If Graham-Cassidy is passed, it would be final, with no room for changes in the House.

And here's the rub: Senate Republicans have only 12 days to pull it off.

In pursuit of making that deadline, lawmakers would have to discard regular order, meaning they wouldn't use the standard procedure to pass a bill. It's not that they haven't done it in the past — the first Senate GOP health care attempt was historically secretive and rushed — but it might be enough to lose Arizona Sen. John McCain's vote once again.

McCain called for a return to regular order, complete with committee hearings, markups, and an open amendment process when he voted against the skinny repeal in July. After a meeting with McConnell Monday, McCain told reporters regular order remained his priority and said he wasn't supportive of the Graham-Cassidy bill yet — despite Arizona Gov. Doug Ducey's endorsement earlier that morning.

Naturally, Republican leaders are trying to woo him. Senate Finance Committee Chairman Orrin Hatch (R-Utah) told reporters Monday night that his committee will hold a hearing on the bill next week, which could provide enough semblance of “regular order” to convince McCain to vote in favor of the bill.

The other two Republican senators who voted against the skinny repeal package, Collins and Murkowski, are far from supportive of the Graham-Cassidy bill.

This new legislation also defunds Planned Parenthood, which may be enough to lose Collins's and Murkowski's support on its own, as that's a big reason why they opted against the skinny repeal. What's more, their states would be among those most impacted by the bill's Medicaid cuts.

GOP leaders do not believe they can obtain Collins's support, although she insists she's still considering the bill. But without a full score from the Congressional Budget Office — which won't be able to calculate all of the bill's impacts before releasing an incomplete preliminary score next week — an affirmative vote looks even more unlikely from her.

Murkowski is also a tough get for Republican leadership, but she met with McConnell and told reporters Monday afternoon she's still reviewing its merits. Her decision could make or break the renewed effort.

For this health care hype to translate into action, two of those Republican senators have to get behind the proposal.

GOP leaders plan to whip the bill during the conference's policy lunch Tuesday afternoon. But for all the talk of gained momentum, Republicans know they're right where they left off.

“We had 99 percent of what we needed. We were only one vote short,” Sen. Tim Scott (R-S.C.) told IJR.

Does this bill have what it takes to get that last vote?

“We're going to start counting. We'll see here shortly,” Scott answered. “I'm sure we're in the high forties now. The question is: Can we get across the finish line?”

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