In a closed-door meeting of Senate Republican chairmen Wednesday, Lisa Murkowski ripped GOP leaders’ attempt to scale back Medicaid spending in their Obamacare repeal bill.

The two matters were unrelated, she argued, because the Affordable Care Act did not change Medicaid spending levels across the entire program. The independent-minded Alaska senator was backed up by Sen. John Hoeven of North Dakota, a Republican generally aligned with leadership, according to senators and people familiar with the conversations.


“The ACA allowed for Medicaid expansion. The ACA didn’t address traditional Medicaid. … Why do we not focus on the urgency of the concerns with the ACA?” she said in an interview afterward. “Let’s deal with the urgency of the issue. Let’s set Medicaid off to the side.”

GOP leaders are set to unveil a new version of their health bill Thursday, but no major changes have been made to satisfy senators concerned about winding down Obamacare’s Medicaid expansion and aggressive Medicaid cuts over the next decade. So even as Senate Majority Leader Mitch McConnell struggles to keep restive conservatives like Ted Cruz and Mike Lee on board, lingering concerns from moderates like Murkowski could signal the bill’s demise.

McConnell needs 50 votes simply to open debate on the bill next week, and he is well short of that number, GOP senators said.

“Not right now. But we don’t need them right now,” said Sen. John Cornyn (R-Texas), the party’s chief vote counter. “We’re going to need them next week.”

Republicans are planning to pump billions more into the health care system to reduce premiums for low-income people, fight opioid addiction and give states money to make health care innovations. But Cornyn said Medicaid is still “one of the biggest challenges” leaders face.

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About a dozen Republican senators have been meeting regularly to air their concerns about changes to the Medicaid program. And since Sen. Rand Paul (R-Ky.) is almost certainly a “no” vote, just two of them could stop the whole measure in its tracks next week on a key procedural vote to take up the bill.

“No breakthroughs. There’s been a lot of discussions. … We remain in the same camp,” said Sen. Dean Heller, one of the stiffest GOP opponents, who is up for reelection in increasingly blue Nevada. “Fundamentally, they haven’t changed the bill.”

McConnell has told senators they will have a chance to amend the bill on the floor and test the popularity of their push to make Medicaid benefits more generous. But Republicans, both conservative and moderate, have instead pressed for all their preferences to be included in the GOP’s base bill, which many suspect will be introduced at the end of the amendment process and overwrite all the changes to the bill.

And a number of Republicans simply don’t believe the Obamacare repeal effort should include major entitlement reform on a partisan basis, which could lead to Republican political ownership of curtailed benefits in the coming years and potentially sweeping electoral losses.

The Senate bill seeks to trim federal Medicaid spending by $772 billion over 10 years, and the nonpartisan Congressional Budget Office estimates it would result in 15 million fewer people being enrolled in Medicaid in a decade.

“Why not take out the issue of the [Medicaid spending] inflation rate and have a series of amendments? … Just don’t deal with it in the base bill,” said Sen. Susan Collins (R-Maine). “A number of us are making the point — I’m not the only one — that Obamacare, except for the expansion, did not change base Medicaid.”

Murkowski said she has made a similar point directly to President Donald Trump, who ran promising to protect Medicaid and trumpeted his stance as being different from those of other Republican presidential candidates.

McConnell has also previously argued that in a divided government, bipartisan work is the best way to tackle entitlement reform. Some senators privately say they are uncomfortable changing Medicaid spending without any buy-in from Democrats, who have attacked the GOP relentlessly for writing a bill that would cut taxes for the wealthy and benefits for the poor.

The Senate bill would end Medicaid as an open-ended entitlement in 2020 by capping how much federal funding government gives to states, and unwinds Obamacare's Medicaid expansion funding starting in 2021. One of the biggest sticking points is the decision to allow federal Medicaid payments to only grow in line with inflation starting in 2025, a proposal insisted upon by Senate conservatives to rein in spending.

To some extent, the Senate bill is even more conservative than the House’s bill when it comes to Medicaid, because the House plan calls for Medicaid growth that at least matches medical inflation, which rises faster.

But removing the overhaul of Medicaid or letting federal payments grow at a more generous rate may not solve the GOP’s math problem. Fiscal conservatives have bought into the bill as an opportunity to restructure Medicaid, and yanking those provisions could cost considerable support on the right. Republicans expect that the conservative-tilting Medicaid language has not changed during the flurry of rewrites over the past two weeks.

“I don’t know that we’ll see any changes in this particular proposal," Sen. Mike Rounds of South Dakota said Wednesday. “I do think that that’s an item which is still a negotiable item in the future. There are some states out there that get impacted differently than others. And so when we look at it, you want to be fair."

Sen. Pat Toomey of Pennsylvania, has clashed repeatedly with advocates of more generous Medicaid spending, such as Sen. Rob Portman of Ohio. Toomey said people who disagree with him on which inflation rate to use are “just waiting for the crisis to occur” in the government’s finances.

"If we’re not willing to slightly slow down the rate of growth at a distant point in the future of the program that is actually driving this deficit the most, if we’re not willing to do even that you just need to admit you want to have the crisis,” Toomey said Wednesday.

Asked Wednesday whether his opposition to the bill over Medicaid cuts has changed, Portman bluntly answered: “No.”

Jennifer Haberkorn contributed to this report.