Paul gives McConnell his vote to open health-insurance debate, then votes against his repeal-and-replace bill; more votes coming

Sens. Mitch McConnell of Kentucky and John
Cornyn of Texas after the vote to start debate
(Washington Post photo by Oliver Contreras)

Kentucky Health News

Senate Majority Leader Mitch McConnell got just the votes he needed to start debate on a health-insurance bill Tuesday, but that night Republicans' "most comprehensive plan to replace President Barack Obama’s health law fell far short of the votes it needed," The New York Times reported.

The latest version of McConnell's Better Care Reconciliation Act needed 60 votes to overcome a parliamentary objection. It got 43, with 57 senators opposing it.

The tally "was an ominous sign for Republican leaders still seeking a formula to pass final health-care legislation this week," the Times' Thomas Kaplan and Robert Pear wrote.

At mid-afternoon, McConnell scored a victory that had eluded him for weeks, getting 50 Republican votes to proceed with debate on a bill, plus Vice President Mike Pence's vote to break a tie. Two Republicans and 48 Democrats voted not to proceed.

Sen. Rand Paul, who had said he would vote to proceed only on a "clean repeal of Obamacare," voted with his Kentucky seatmate after weeks of disagreement. Paul had tweeted, “This morning, @SenateMajLdr informed me that the plan for today is to take up the 2015 clean repeal bill as I’ve urged,” Paul this morning. “If that is the plan, I will vote to proceed to have this vote. I also now believe we will be able to defeat the new spending and bailouts.” Later, Paul voted against McConnell's bill.

UPDATE, July 26: The Senate voted 55-45 Wednesday afternoon against a Paul amendment that would have repealed Obamacare but delayed the effective date for two years. Among those voting no was Sen. Lamar Alexander, R-Tenn., chair of the Senate health committee.

Earlier, McConnell had secured the votes of Sens. Dean Heller of Nevada, Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who have been concerned about McConnell's plan to phase out expanded funding of Medicaid and scale back the entire program. Kentucky also has hundreds of thousands of people on Medicaid through the expansion.

The three senators "hoped McConnell could be persuaded to add $100 billion in spending aimed at blunting those cuts, but leadership was caught between them and fiscal conservatives," Politico reported. "In front of McConnell and the rest of the caucus, [President] Trump told Republican senators that 'We’re going to add this money to the bill,' according to two sources familiar with the matter."

The last vote came from Sen. Ron Johnson of Wisconsin, who had criticized McConnell for telling moderates that the Medicaid cutbacks would never come to pass. At McConnell's desk on the Senate floor, "The two engaged in a tense, 10-minute face-to-face talk. McConnell’s face turned increasingly red, and the GOP leader threw up his hands multiple times," Politico reported.

But after Sen. John McCain returned from surgery and a brain-cancer diagnosis and voted yes, Johnson was on the spot. "Left with the option of being the Republican who killed Obamacare repeal or the one who saved it, the Wisconsin senator quickly flipped a thumbs-up into the air to vote yes," Politico reported. All 48 Democrats then voted no, causing the tie that Pence broke.

"That McConnell even got to this point was remarkable," wrote Politico's Jennifer Haberkorn, Seung Min Kim and Burgess Everett. "Just a week ago, the GOP’s repeal-and-replace effort was practically declared dead, as the GOP leader himself said it was 'pretty clear' there weren’t 50 votes for a health-care bill."

"In the end, it was McConnell’s binary choice argument that reeled in the 50 votes. McConnell relentlessly laid out his reasoning . . . a vote against even debating Obamacare repeal is a vote to keep it in place."

McCain's return gave McConnell momentum and made the difference, but in an emotional floor speech he urged Republicans to work with Democrats on a solution to the issue, "something that my dear friends on the other side of the aisle didn’t allow to happen years ago."

Politico reported, "The Arizona senator left open the question of whether he would help his fellow Republicans eventually pass a bill now that debate has begun. And though clearing Tuesday’s procedural hurdle was almost certainly McConnell’s most hard-fought victory of the year, passing legislation is another matter."

The debate will be mainly on a series of amendments, few if any of which are likely to pass. "The end goal is likely a stripped-down repeal of Obamacare’s individual and employer mandates and the law’s medical device tax, perhaps with more add-ons. The GOP will now pass whatever can garner 50 votes, no matter how scaled-back McConnell’s ambitions of repealing Obamacare 'root and branch' have become," Politico reported.

"Their hope is to get something to the House and get it off the Senate’s plate. With any luck, senators say, they will end up in a bicameral conference and finish the job later this year. And now that McConnell has won a vote to proceed to an uncertain outcome, no one is counting him out."

UPDATE, July 26: Obamacare supporters warned that a House-Senate conference could revive the repeal-and-replace idea. Republican moderates would find it more difficult to vote against a repeal-and-replace bill coming out of a conference because it would not be subject to amendment. “It’s either take it or leave it,” Jacob Leibenluft, of the liberal Center on Budget and Policy Priorities, told Tony Pugh of McClatchy Newspapers. “Either that bill passes or those senators [who vote against it] will be held responsible for preserving the Affordable Care Act in the minds of their Republican voters.”

The Blue Cross Blue Shield Association said the individual mandate should not be repealed without something to replace its role in stabilizing insurance markets. "We need strong incentives for younger, healthier people to obtain coverage and for everyone to stay covered year-round," the insurers said in a statement. There is no effective replacement for the mandate, Sherry Gleid and Adlan Jackson write for The Commonwealth Fund.

UPDATE, July 27: Ten governors, five from each party, told McConnell in a letter that they opposed the stripped-down bill, dubbed "skinny repeal," and that Congress should focus on stabilizing insurance markets.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.