Senate Republican leaders racing to finalize their health care bill want to preserve Obamacare’s central protections for people with pre-existing conditions to avoid the firestorm that nearly derailed the House’s repeal effort a few months ago.

But Senate Leader Mitch McConnell can’t afford a conservative rebellion as he attempts to ram through an Obamacare repeal bill before the July 4th recess.


So while the emerging Senate plan attempts to win over moderate Republicans by keeping the health law’s bar on discriminating against the sickest Americans, it would also give states flexibility to alter their health markets in ways that could weaken coverage for millions with pre-existing conditions.

The something-for-everyone Senate plan embodies the tug-of-war shaping a GOP repeal effort that needs to win the support of 50 of the conference’s 52 senators. Senate Republicans are grappling with sharp differences of opinion over how far to roll back Obamacare’s regulations, a debate that’s pitted the party’s more moderate members against the conservative trio of Sens. Ted Cruz, Mike Lee and Rand Paul.

President Donald Trump has urged Republican senators to craft a bill with more “heart” than the House-passed Obamacare repeal legislation, and much of the work to this point has focused on softening some of the House’s harshest provisions.

Yet for all the focus on winning over moderates and broadening the repeal bill’s appeal, Senate Republicans are painfully aware that the objections of the conference’s small but stubborn right flank could leave them short of the needed 50 votes, abruptly sinking the GOP’s entire repeal effort.

“The people who have reservations are making their points,” said Sen. David Perdue (R-Ga.) considered likely to support the bill. “I’m nervous, but I’m still hopeful.”

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That dilemma threatens to make the next week a repeat of the drama that played out on the other side of the Capitol. House Republicans were forced to abandon a repeal vote in March after the conservative Freedom Caucus revolted against a bill they felt didn’t go far enough in gutting Obamacare regulations. It took another month before revised legislation that critics say would make health care unaffordable for many older and sicker people squeaked through the House.

Senate Majority Leader Mitch McConnell, who set an end-of-month deadline for a vote, faces a tougher challenge: Republicans need support from at least two of the Cruz-Lee-Paul faction to pass the bill. And so far, they show few signs of budging on demands that, if granted, risk alienating even more of the conference’s moderate wing.

Cruz, Lee and Paul have pushed for a “true” repeal of Obamacare, including potentially eliminating standards for what insurers can charge and how much their plans have to cover, and whether they can discriminate against people with pre-existing conditions. They argue that those regulations are prompting insurers to hike premiums and raise deductibles, creating health plans that people are forced to purchase but can’t afford to use.

Paul has also railed against proposals boosting the tax credits included in the House-passed bill and designed to help older Americans purchase coverage, deriding them as a new entitlement.

“If our bill comes in with greater subsidies than Obamacare, I think it’s going to be harder for conservatives to support,” he said. “That, to me, is really a nonstarter.”

But that view is not shared by Republican moderates. After watching their House colleagues get skewered for letting states waive pre-existing condition protections, several GOP senators pledged to make sure their version shields sick people.

McConnell’s approach so far appears aimed at splitting the difference in hopes of assembling a coalition that spans the ideological spectrum.

The Senate bill is likely to give states the ability to opt out of major parts of Obamacare in favor of developing their own rules, including eliminating the requirement that all insurers cover a prescribed set of health benefits. States could also redefine what constitutes a quality health plan. Those are both nods to GOP conservatives who believe loosening insurer standards would promote competition and give people more customized — and cheaper — insurance options.

But the legislation is expected to bar proposals that would allow insurers to adjust premiums based on health status. That would keep Obamacare’s strongest pre-existing condition protection in place, and meet a key requirement for senators weighing whether the bill cares for the nation’s sickest.

“Bottom line is that we are going to make sure that we maintain protections for pre-existing conditions, because we think it’s obviously the most important thing to do,” said Sen. Tim Scott of South Carolina.

Still, that represents a narrow path to 50 votes — and one that’s not guaranteed to work. Under the Senate GOP’s proposal, states waiving Obamacare’s essential health benefits could free insurers to charge dramatically more for plans that cover complex and expensive medical needs. Without strict limits, that threatens to amount to a backdoor penalty on sicker Americans – undermining Republican claims to protecting people with pre-existing conditions.

“I want states to have more flexibility, but I think coverage for mental illness and substance abuse for example, and maternity care are essential,” Sen. Susan Collins of Maine said as she headed to a GOP lunch to discuss the bill, clutching a sheet listing Obamacare’s 10 required health benefits. “So, we’re going to have to see.”

Even if McConnell can convince enough skeptical centrists to back the bill, he’ll still need to hope that the conference’s conservatives decide partial repeal is better than no repeal at all.

Paul, who has advocated for a comprehensive rollback of Obamacare’s regulations, is already viewed as a near-guaranteed “no” on any Senate bill that fall short of that high bar.

Sen. Mike Lee, considered perhaps the Senate’s most conservative member, has warned of “grave concerns” with the Senate’s direction.

And despite repeated assertions that “failure is not an option,” Cruz’ optimism has sounded more guarded in recent days.

“We’re making progress,” he said, a week out from a potential Senate vote. “But we’ve got a lot of work to go.”