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Defector of the Day: Mike Lee

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate. Today we look at one of the most prominent conservative opponents of the current bill: Sen. Mike Lee (R-UT).

It seems the fate of the Senate health care bill will hinge, in large part, on whether Mike Lee is satisfied.

The Utah Republican has chosen his words carefully throughout the past few months. He participated in the private working group meetings that helped give the bill shape, representing, along with Ted Cruz, the wishes of the most anti-Obamacare members of the GOP caucus.

Now he's making his big demand: On Thursday, Lee conditioned his support for the Senate bill on an amendment proposed by Cruz.

His spokesperson told Axios's Caitlin Owens that without the Cruz proposal, Lee would oppose the final bill. Without Lee, it becomes hard to imagine a path for the legislation to pass; 50 of the 52 Senate Republicans must vote for it.

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We covered the Cruz amendment at length last week. The gist is this: Health insurers could sell non-Obamacare plans as long as they also sold Obamacare-compliant insurance. It would give conservatives a big win on insurance regulations, which have been their No. 1 priority because they believe loosening regulations will lower premiums.

The proposal does erode Obamacare's protections for people with preexisting medical conditions, because it would likely segment the insurance market into healthy and sick pools. Healthy people would buy non-Obamacare plans, while sick people would buy the more robust Obamacare coverage. That would drive up premiums for the latter market.

Many people would be protected from those increases in part through Obamacare's financial assistance. But the market would then depend on an effectively unlimited commitment by the federal government to pay the skyrocketing bills. Experts are doubtful that Uncle Sam would be able to keep that commitment.

Nevertheless, conservatives want to roll back Obamacare's insurance regulations, and the Cruz plan is their preferred way to do it at this stage of the negotiations. We know McConnell is having the plan evaluated by the Congressional Budget Office this week, likely to get a sense of its policy impact and to make sure that it complies with the Senate's procedural rules.

Lee is making this the price of his support for the Senate plan. He and Cruz would likely bend on other provisions — like repealing Obamacare taxes — if they can claim a win on the insurance rules. That could make it easier for McConnell to pick off moderate votes.

Then again, adding the amendment alone could drive away moderate votes. Obamacare's insurance protections are among the law's most popular policies, and many Republicans want to keep them.

Without Lee and with a half-dozen others opposing the current draft, the math starts to become insurmountable.

Meanwhile, from Mitch...

McConnell is starting to play some real hardball with his wayward Republicans: He's threatening bipartisanship.

"If my side is unable to agree on an adequate replacement, then some kind of action with regard to private health insurance markets must occur," he said Thursday.

It certainly reads as a warning to the holdouts: If we don't pass this bill, we will have to take some action that enshrines Obamacare.

It's also an acknowledgement of the obvious. Failure is a real possibility. And if Republicans can't coalesce around their own plan, they'll have to do something to shore up the health care law.

Chart of the Day

Centene fills Missouri's empty counties. You might have missed it in the rancor over the health care debate in Washington, but health plans have been stepping in to fill Obamacare's bare-shelf markets. Missouri is now the latest state to benefit, after Centene announced it would sell plans there next year.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

“Senate Republicans say they're weeks away from healthcare vote”: “Republican senators are downplaying the chances of a quick vote next week on their ObamaCare replacement bill amid divisions in the party over what the legislation should look like. ‘We're still several weeks away from a vote, I think,’ Sen. Pat Toomey (R-Pa.) said at an event Wednesday.” —Peter Sullivan, the Hill

“Republican senators are downplaying the chances of a quick vote next week on their ObamaCare replacement bill amid divisions in the party over what the legislation should look like. ‘We're still several weeks away from a vote, I think,’ Sen. Pat Toomey (R-Pa.) said at an event Wednesday.” —Peter Sullivan, the Hill “Ted Cruz’s Plan to Save Republican Health-Care Bill Gains Traction”: “Senate Republican leaders, in a bid to salvage their health overhaul, are weighing the merits of a proposal by Sen. Ted Cruz (R., Texas) to let insurers that sell plans that conform to the Affordable Care Act’s regulations also sell policies that don’t. The idea, also backed by Sen. Mike Lee (R., Utah), would allow insurers to offer cheaper, less-comprehensive policies, likely to be bought by healthier people.” —Stephanie Armour and Kristina Peterson, Wall Street Journal

“Senate Republican leaders, in a bid to salvage their health overhaul, are weighing the merits of a proposal by Sen. Ted Cruz (R., Texas) to let insurers that sell plans that conform to the Affordable Care Act’s regulations also sell policies that don’t. The idea, also backed by Sen. Mike Lee (R., Utah), would allow insurers to offer cheaper, less-comprehensive policies, likely to be bought by healthier people.” —Stephanie Armour and Kristina Peterson, Wall Street Journal “GOP activists put Congress on notice: Repeal Obamacare or get voted out”: “Frustration is mounting among Republican activists over the GOP’s continued failure to repeal and replace Obamacare, with grassroots groups now warning of consequences for lawmakers in the 2018 elections if the Senate doesn’t reach a deal soon.” —Katie Glueck, McClatchy

Analysis and longer reads

“Opioid Prescriptions Falling But Remain Too High, CDC Says”: “A new report out Thursday offers a bit of hope: Doctors are prescribing opioids less often, and the average dose they're giving patients has dropped, according to the Centers for Disease Control and Prevention. However, the number of patients getting opioids is still too high, and doctors are giving their patients prescriptions that last longer, according to the report in the CDC's Morbidity and Mortality Weekly Report.” —Rob Stein, NPR

“A new report out Thursday offers a bit of hope: Doctors are prescribing opioids less often, and the average dose they're giving patients has dropped, according to the Centers for Disease Control and Prevention. However, the number of patients getting opioids is still too high, and doctors are giving their patients prescriptions that last longer, according to the report in the CDC's Morbidity and Mortality Weekly Report.” —Rob Stein, NPR “Beyond ‘ To Close Or Not To Close ’ Rural Hospitals”: “The RCHI [Rural and Community Health Institute] team challenges conventional policy conversations and goes beyond solely focusing on a community losing a hospital. Instead, the authors look at the problem through a geographic lens and focus on what are the available health resources in the affected areas. The report finds that a regional approach is key to developing health care alternatives for rural communities, such as expanding telemedicine options, converting a former hospital into a freestanding emergency department, or establishing new rural health clinics.” —Shao-Chee Sim, Health Affairs

“The RCHI [Rural and Community Health Institute] team challenges conventional policy conversations and goes beyond solely focusing on a community losing a hospital. Instead, the authors look at the problem through a geographic lens and focus on what are the available health resources in the affected areas. The report finds that a regional approach is key to developing health care alternatives for rural communities, such as expanding telemedicine options, converting a former hospital into a freestanding emergency department, or establishing new rural health clinics.” —Shao-Chee Sim, Health Affairs “As family members dominate caregiving, outside support is hard to find”: “In 2015, roughly 34 million Americans provided unpaid care to an adults age 50 or older in the last 12 months, according to figures from the National Alliance for Caregiving and AARP. Unpaid end-of-life caregivers provide nearly double the hours of support per week compared to other caregivers, but they did not receive additional pay from government or private insurance, according to the Health Affairs study.” —Steven Ross Johnson, Modern Healthcare

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