Sen. Shelley Moore Capito, R-W.Va., announced Tuesday she was against the current version of the Senate GOP health care bill. (Photo: J. Scott Applewhite/AP)

Janice Hill almost didn’t get on the bus. But last week, she found herself riding along with three dozen other West Virginians on a motorcoach to the nation’s capital, where she soon came face to face with one of the most elusive figures in the debate over Republican efforts to repeal the Affordable Care Act: her home state’s junior senator, Shelley Moore Capito.

Hill, a pastor from Parkersburg, W.Va., usually doesn’t fumble for words, but she was suddenly nervous. Their group, in town to lobby against the GOP health care bill, had not expected to see Capito, a centrist Republican who had been dodging the spotlight for days amid intense lobbying from both sides.

Like others in the room, Hill had called and emailed Capito’s office about health care, but now, standing just a few feet away from the lawmaker, she had no idea what to do. Suddenly, she felt compelled by an “impulse,” as Hill later put it. The pastor stood and approached Capito with her iPhone, and with her hands shaking, she pulled up a photo of her adult daughter Amy, who was diagnosed four years ago with neuroendocrine small-cell carcinoma, a rare form of cancer.

In an exchange that was filmed by someone else in the room and later posted on Facebook , where it has been viewed more than 5 million times, Hill showed the senator photos of Amy before and after her diagnoses, when she was in the hospital undergoing treatment. In the latter photo, Amy has no hair and is lying in her hospital bed in a fetal position. “Oh my god,” Capito responded, as she grabbed Hill’s phone to look closer.

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“I wanted her to see a face. I wanted her to see the face of someone whose life depends on health care, someone who would be directly impacted by the vote she would cast,” Hill recalled this week. “I wanted her to carry that face with her, to remind her that what she was about to do was going to have impact on real people.”

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Whether Hill’s story influenced Capito is unknown. But on Tuesday, after Senate GOP leaders announced they were delaying a planned vote this week on the ACA repeal until after the July 4th congressional recess, Capito finally ended weeks of speculation and added her name to the growing list of Republicans who say they do not support the bill as currently written.

In a joint statement issued with Sen. Rob Portman, a Republican from neighboring Ohio who has also been a wild card in the debate, Capito cited her concern over proposed cuts to Medicaid, which could potentially devastate rural health care providers who have been on the frontlines against an opioid epidemic in her state that is considered among the worst in the country.

“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,” Capito said in the statement.

Sen. Shelley Moore Capito with Sen. Mike Lee, R-Utah, and Sen. Bob Corker, R-Tenn., at a White House meeting on the health care bill, June 27, 2017. (Photo: Alex Wong/Getty Images)

But as Senate Republicans scramble to regroup and come up with a bill that can gain enough support to pass, the pressure is only likely to increase on Capito. She is seen as a genuine swing vote in the battle over health care reform, and as such, she has faced intense lobbying both in Washington and at home. Her dilemma is how to strike a balance on an issue that has galvanized her party and her supporters who want to see Obamacare overturned, and doing right by constituents who would be hit harder than residents of wealthier states by drastic cuts in health care.

West Virginia is unquestionably Donald Trump country — a state where voters strongly responded to the GOP candidate’s vows to revive the coal industry, create jobs and, as Trump often put it, represent the nation’s “forgotten people” in Washington.

But while many voters in West Virginia rage against much of what President Obama did, including his efforts on climate change, the state has strongly benefited from Obamacare, which gave health insurance to many residents of this largely rural state for the very first time. According to U.S. Census Bureau numbers cited by Politifact, the proportion of uninsured individuals between the ages of 18 and 64 went from an average of 21 percent between 2008 and 2013 to 9 percent in 2015 — one of the biggest declines in the country.

West Virginia was among the 31 states that took advantage of a provision in the ACA allowing states to extend Medicaid to millions of low-income adults who could not otherwise afford health care. Under the plan, the federal government reimbursed 100 percent of health care costs for those who qualified. The federal government was scheduled to continue reimbursing those costs at a rate of 90 percent starting this year and beyond, with states making up the rest, but the Senate GOP bill, echoing legislation already approved by the House, would not only eliminate that expansion but also cut Medicaid funding by $722 billion, according to the Congressional Budget Office.

Those cuts could be potentially devastating in West Virginia, where more than 564,000 residents or roughly 29 percent of the state are on Medicaid, according to the Henry J. Kaiser Family Foundation. That includes nearly 172,000 who currently have insurance through the Medicaid expansion, according to the latest numbers from the West Virginia Department of Health and Human Resources (WVDHHR).

Confounding Capito’s dilemma is that rural health care providers, who rely heavily on Medicaid reimbursements, have been on the frontlines of the fight against opioid abuse. Many of those covered by Medicaid have been caught up in the epidemic. According to the WVDHHR, roughly 50,000 of those who were covered through the Medicaid expansion received treatment for substance abuse last year — a number many state officials expect to increase amid a drug crisis that only appears to be getting worse by the day.

Sen. Bernie Sanders speaks at a rally against Trumpcare in Charleston, W.Va., June 25, 2017. (Photo: Maddie McGarvey/Getty Images for MoveOn.org)

Amid the proposed Medicaid cuts, Capito and Portman were among a group of senators from states struggling with the opioid crisis who pressed Senate Majority Leader Mitch McConnell and other lawmakers working on the health care bill to supplement the cuts with a $45 billion fund to combat and treat drug abuse. But that plan came under criticism from both conservatives intent on using the ACA repeal bill to cut the federal budget deficit and from health officials who argued that plan wouldn’t be enough to counteract funding cuts to rural hospitals dealing with the crisis.

Capito has said little about how she plans to move forward. Her office, which did not respond to requests for comment, has offered few details about what Republican leaders could offer to win her support for a bill. She has repeatedly argued for changes to ACA, which she has described as a “broken law,” including efforts to lower premiums and entice insurance providers into staying in markets to offer more competition.

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Back home, Capito has been bombarded by groups on both sides of the debate. In recent days, local television stations in Huntington and Charleston featured frequent ads calling on voters to contact Capito and urge her to vote one way or the other. Vermont Sen. Bernie Sanders held a rally in Charleston last Sunday that attracted more than 2,000 people in which he called on Capito to vote against the GOP bill. Meanwhile, six protestors, including a priest, were arrested in a sit-in at her office in Charleston on Monday, and opponents of the bill are already planning to step up their calls and lobbying during next week’s recess. As of Wednesday, Capito had no public events scheduled for next week.

Back in Parkersburg, Hill said she hadn’t heard from Capito’s office — though it seems she’s heard from everyone else. The video of her exchange with Capito went viral, eliciting calls from dozens of reporters. She’s told her story on CNN and MSNBC. “I’ll talk to anyone to save my daughter,” she said.

Hill credits protections under the ACA, which bans insurers from placing lifetime or yearly limits on how much they spend on patient benefits, for saving her daughter’s life — limits that would be removed under the law being considered in the Senate. In her first seven months of treatment, Amy, who is 41, racked up more than $1.2 million in medical bills — which was largely covered through her employer-backed insurance. And she continues to receive treatment. “She would not be alive today if not for the ACA,” she told Capito last week.

Asked if she thinks she made an impact on Capito’s thinking about the bill, Hill said she wasn’t sure, but she hoped so. “I think she listened to me. I think when she saw the picture of my daughter, how beautiful she is, and then when she saw her in treatment, she had an emotional reaction, a real response,” Hill said. “I wanted it in her head that her vote is going to affect this person that she’s looked at, and I think, I hope, it did.”

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