Senate Republicans’ health care fight is getting personal.

Senate Majority Leader Mitch McConnell and Sen. Rob Portman, close allies and typically mild-mannered men, got into a heated exchange over Medicaid at a meeting earlier this week.


McConnell sided with conservatives eager to dramatically slow the program’s growth, and laid into Portman for opposing it.

“As OMB director, you backed entitlement reform,” he said, according to multiple GOP sources in the leadership meeting. Portman was Office of Management and Budget director under President George W. Bush, and McConnell was implying that Portman had changed his stance from when he worked in the White House.

But Portman, who has backed individual spending caps for Medicaid under the GOP plan but not the slower growth, was having none of it.

“The leadership has overreached on this bill,” Portman shot back.

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The tense back-and-forth between the GOP leader and a normally reliable Republican colleague shows just how high the stakes have become as McConnell struggles to assemble a Senate majority to repeal Obamacare and enact a GOP health care plan.

In an embarrassment for McConnell and President Donald Trump, Republicans were forced to delay any vote until early July — if it happens at all — when he couldn't even find the votes to take up his proposal this week, much less pass it.

Portman’s opposition shows just how far McConnell is from getting the 50 votes he needs to pass the bill. It’s not a matter of several conservatives or moderates not supporting the proposal. McConnell appears to be as many as 15 to 20 votes shy of majority support.

“Getting the policy right is important, and Rob always appreciates the opportunity to have an open and honest dialogue with his colleagues,” said Kevin Smith, Portman’s communications director, in a statement.

Portman declined to comment for this article. McConnell’s office also declined to comment.

As a former member of the House leadership and one-time OMB director who was reelected by a big margin in November, Portman carries a lot of weight among his fellow Republicans. It’s not that Portman controls these fellow GOP votes. It’s that with someone like Portman opposed, it makes it much easier for wavering Republicans to vote no as well.

“I think Sen. Portman has taken a very patient-centered approach in the sense that he is thinking about vulnerable families, specifically with opioid addiction, which President Trump displayed great empathy for during the campaign,” said Sen. Bill Cassidy of Louisiana, another holdout on the bill who said he shares some of Portman's concerns about the plan. “If he were satisfied, I think that would go a long way.”

Portman also finds himself squeezed between McConnell and Trump on one side and his popular Republican governor, John Kasich, on the other — a dynamic that has complicated the prospects of securing votes from other GOP senators from Medicaid expansion states, most notably Sen. Dean Heller of Nevada.

Trump and McConnell are pushing to cut Medicaid by more than $700 billion. Kasich called the GOP plan “completely inadequate" and is urging Senate Republicans to amend the bill.

"I’m not going to comment on Sen. Portman’s position," fellow Ohio Sen. Sherrod Brown, a Democrat, said Wednesday. "I will say that Gov. Kasich has said putting money that’s stripping away insurance and then putting a federal grant in of whatever amount is spitting in the ocean. That’s what the governor of Ohio, Republican governor, said."

Portman, though, is catching heat inside the Capitol for his opposition, as demonstrated by his clash with McConnell. One GOP leadership staffer, speaking on condition of anonymity, labeled Portman "Sen. No," suggesting the Ohio Republican didn't want to reach a deal and shifted his demands during the negotiations.

Sources close to Portman vehemently denied any such motivation.

Portman "has been consistent" in what he has sought for months, one source asserted, pointing out that Portman and Sens. Shelley Moore Capito (R-W.Va.), Lisa Murkowski (R-Alaska) and Cory Gardner (R-Colo.) sent a letter to McConnell in early March laying out their concerns with House Republicans’ bill to change Medicaid. Now McConnell and Senate GOP leaders want to go even further than the House plan, though Portman did agree to a cap on spending per patient in Medicaid — a provision that Democrats strongly oppose.

Portman is also highly critical of the McConnell plan for what he sees as insufficient funding for fighting the opioid crisis, a major issue for the Ohio Republican. Portman and some other GOP moderates are seeking $45 billion to deal with the crisis, while the current GOP draft includes only $2 billion in new funding — although Senate Republicans and the White House have since agreed to add at least $45 billion to address the epidemic. That could help persuade Portman in favor of the bill.

Portman and Capito, who have been holding regular meetings with roughly a dozen senators on Medicaid, jointly came out in opposition to McConnell’s proposal on Tuesday, shortly after the Kentucky Republican delayed any vote on his plan until after the July Fourth recess.

“The Senate draft before us includes some promising changes to reduce premiums in the individual insurance market, but I continue to have real concerns about the Medicaid policies in this bill, especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic," Portman said in a statement.

The Portman-Capito “Medicaid expansion” group of Republican senators has been meeting regularly for months, including weekly sessions as McConnell crafted his leadership plan.

Other GOP senators who have taken part in these meetings include Murkowski, Gardner, Cassidy, Heller, Susan Collins of Maine, John Hoeven of North Dakota, John Boozman of Arkansas, Todd Young of Indiana, Chuck Grassley of Iowa and Thom Tillis of North Carolina, among others.

A number of these senators pushed for a longer phaseout period for repealing the Obamacare expansion of Medicaid than had been included in the House plan. For now, the Senate Republican proposal continues the additional federal payments to Medicaid expansion states for four years, but starting in 2021, the payments would start getting rolled back over a three-year period to traditional Medicaid funding rates.

Portman and Sen. Pat Toomey (R-Pa.) have clashed over the growth rate used to calculate Medicaid spending. Toomey wanted to use a rate tied to core inflation, while Portman supported using a rate tied to medical inflation, which is usually higher. The difference could be billions of dollars. McConnell sided with Toomey.

As Republicans continue to negotiate provisions in their health care bill, securing Portman's support could go a long way toward nailing down 50 votes for the measure — as long as leaders don't lose senators from the conservative end of the spectrum who have pushed for a fuller dismantling of Obamacare.

"It’s all about striking a balance," said South Dakota Sen. John Thune, the third-ranking Senate Republican. "And I think Rob has been a very strong vocal advocate for his position and I think he’s gotten some additional funding as a result of that."