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Why the Senate’s Latest Health Care Bill Still Looks Like It’s Doomed

Senate Republican leaders unveiled a new version of their health care legislation Thursday. But, judging from initial reactions, it may not prove the elusive Obamacare-slaying silver bullet the GOP has been seeking for some seven years.

To be clear: this bill is still not officially dead. Previous attempts to divine health care reform’s fate have proven foolhardy (or at least ill-fated). And given the monumental political pressure on Republicans to fulfill their long-standing promise to dismantle Obamacare, anything is possible. But a first read of the new draft (and, notably, it’s still being called a “draft”) and a number of skeptical lawmaker statements suggests this is one legislative rabbit that political wizard Senate Majority Leader Mitch McConnell could have trouble pulling out of his hat.

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At least two GOP Senators—Maine’s Susan Collins and Kentucky’s Rand Paul—say they’re still adamantly opposed to the legislation in its current form. In fact, they’d vote against the “motion to proceed” that would even bring the Better Care Reconciliation Act (BCRA) to the floor of the Senate for consideration.

That particular pairing of naysayers is telling; respectively, they represent the moderate and conservative factions of the Republican party. And McConnell and his lieutenants, so far, haven’t been able to herd them into a cohesive political flock. Each time the BCRA has been modified to meet moderates’ demands—say, by adding far more money to tackle the opioid addiction crisis, as the latest draft does—some other provision upsets the right-wing (such as the investment income taxes which affect the wealthy that are now being kept in the bill).

The BCRA’s newest iteration also contains a controversial amendment from Texas Republican Sen. Ted Cruz that some health policy experts and major insurance companies have warned could catalyze a race-to-the-bottom. Under Cruz’s somewhat complicated amendment, insurers would be able to offer plans that don’t comply with various Obamacare standards (protections for those with pre-existing conditions, mandated benefits, etc.) as long as they also offer a plan that does comply with those standards.

The trouble with that setup is that it could, as the America’s Health Insurance Plans (AHIP) trade group recently warned, substantially raise premiums for the sick and medically needy, who would stampede over to the more generous Obamacare-compliant plans and thus make those plans far more costly. Meanwhile, the healthy, young, and richer Americans could easily opt for the “skinnier” coverage that doesn’t cost as much. Republicans’ new bill attempts to mitigate these concerns with huge new pots of market-stabilizing funding for insurers—which is, ironically, one of the features that Cruz’s fellow conservative Paul has deemed a non-starter.

Ultimately, deep cuts to Medicaid—still preserved in the new bill—could be its undoing among moderates like Nevada’s Dean Heller (who now says he’s undecided but has previously trashed the GOP’s proposals), Ohio’s Rob Portman (who expressed some skepticism about the legislation Thursday), and Alaska’s Lisa Murkowski (who was able to wrangle a very Alaska-centric measure into the BCRA, though it’s not clear if that will be enough to win her vote). Only one other naysayer aside from Collins and Paul would be necessary to scuttle it.

The Congressional Budget Office is soon slated to release its analysis of the latest health care bill draft. But it’s difficult to see how any of the modifications would significantly change the agency’s initial assessment that tens of millions of people would lose health coverage compared with if Obamacare remains in place.