PROVIDENCE, R.I. - The White House launched an aggressive drive Friday to persuade key Republican governors to stop criticizing a Senate proposal to overhaul the nation's health-care system, urgently pressuring them in public and private ahead of a decisive week for the controversial legislation.
Despite the administration's sales pitch, however, four influential governors reiterated their concerns about the bill's impact on their states' most vulnerable individuals - underscoring the challenge facing the White House and Senate Republicans as they seek to fulfill a seven-year GOP promise to undo the Affordable Care Act (ACA).
"I've still got to come back to my concerns with regard to the Medicaid population," said Nevada Gov. Brian Sandoval, R, on his way to a private session with Vice President Mike Pence here at the summer meeting of the National Governors Association. Pence had earlier delivered a detailed speech to the entire group defending the bill.
Sandoval's views, along with those of three other governors whose states expanded Medicaid under the ACA - John Kasich of Ohio, Doug Ducey of Arizona and Asa Hutchinson of Arkansas - could prove decisive in determining whether the Senate passes legislation next week. Republican senators from those states are closely watching how their governors respond to the newly revamped legislation as they decide whether to support it.
Kasich, who did not attend, issued a statement calling the revised Senate plan "still unacceptable" because of its Medicaid cuts and possible impact on the private ACA insurance market.
Pence joined Tom Price, President Donald Trump's health and human services secretary, and Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, to work governors in front of cameras and behind the scenes Friday in this waterfront city.
They offered a detailed pitch contrasting with the more general and sometimes contradictory rhetoric Trump has delivered on health care - but one that contained inaccuracies and quickly met with rebukes from health advocates. They claimed, for instance, that the bill would not throw millions off insurance and that disabled Americans have been denied care because of the expansion of Medicaid under the ACA, which is also known as Obamacare.
In his speech, Pence also said the ACA's expansion of Medicaid put "far too many able-bodied adults" on the program.
"I know Governor Kasich isn't with us, but I suspect that he's very troubled to know that in Ohio alone, nearly 60,000 disabled citizens are stuck on waiting lists, leaving them without the care they need for months or even years," said Pence.
The waiting lists Pence referred to apply to Medicaid's home and community-based services, and have not been affected by the program's expansion under the ACA. States have long had waiting lists for these services, and the Henry Kaiser Family Foundation's executive vice president, Diane Rowland, noted that waiting lists in non-expansion states are often longer than in expansion states, which currently receive a 95 percent federal match for their newly covered beneficiaries.
Kasich spokesman Jon Keeling said in an interview that Pence's suggestion that 60,000 disabled Ohioans remain on waiting lists "is not accurate," adding that to suggest Medicaid expansion hurt the state's developmentally disabled "system is false, as it is just the opposite of what actually happened."
"That waiting list is nothing new, and to attribute it to expansion is absurd," said Families USA's senior director of health policy, Eliot Fishman.
Moreover, the expansion population is not solely composed of able-bodied beneficiaries: It includes low-income parents and childless adults, some of whom have chronic illnesses.
The Senate Republican proposal would cut $772 billion from Medicaid over the next decade by phasing out the expansion population, and it makes even deeper cuts starting in 2025. By 2036, according to the Congressional Budget Office (CBO), the government would spend 35 percent less on Medicaid than under the current law.
Among the GOP senators who have questioned aspects of the Senate proposal, at least half a dozen hail from Medicaid-expansion states. Pence, a former governor of Indiana, expanded Medicaid in his state.
Under the Senate bill, roughly 15 million Medicaid recipients would lose coverage within a decade, according to the CBO, which is expected to provide an updated score on the revised legislation next week. But Trump officials are arguing that the administration can cushion the bill's financial blow to the states through a combination of legislative provisions and administrative measures.
In a departure from the president, who often has seemed to have little grasp of health policy details and the effect of them on everyday people, Pence delivered a speech in which he recounted stories of individuals he has met across the country who he said have been harmed by the ACA.
He named a Kentucky small-business owner who he said was struggling under increasing premiums, a disabled Ohio woman who he said lost her plan and doctor, and a Wisconsin grandmother who he said had to choose between paying for coverage and buying Christmas presents.
At least one Republican governor may have been swayed by the pitch: Tennessee Gov. Bill Haslam.
Haslam, whose state did not enter into the expanded Medicaid program, nonetheless had some concerns about the Senate legislation's impact on Tennessee, but he said he came away feeling better about the bill after hearing from administration officials.
"I definitely feel more positive about it," he said. "I was generally much more favorably impressed than I expected to be. They had a lot better story to tell than I thought."
GOP leaders have no margin for error as they seek to persuade several wavering senators to embrace the Senate plan. With the vice president prepared to cast the tiebreaking vote, 50 out of 52 Republican senators would have to approve the measure for it to pass.
Two already have said they object to voting on the bill in its current form: conservative Rand Paul of Kentucky and centrist Susan Collins from Maine. A third, Sen. John McCain, R-Ariz., said Thursday that the proposal did not address the concerns his governor has raised and that he would seek to change it.
Ducey met with Pence and his colleagues but said he still has reservations about the Senate bill. "It needs work," he said. "We're communicating with Senator McCain. We've given him specific language that we think will dramatically improve the bill, and the ball's in the Senate's court."
Until now, the White House has taken a largely hands-off approach to the Senate process, although Trump has said he would be "angry" if the bill fails and compared the effort of brokering a deal in the Senate to the quest for Mideast peace.
Sandoval, who is very popular in Nevada and whose reservations helped prompt Sen. Dean Heller, R-Nev., to come out against the original measure before the July Fourth recess, reiterated his dislike of the latest version of the bill as he made his way to an early meeting here Friday.
"My position has been consistent all along with regard to protecting the Medicaid expansion population," he said. "For Nevada that means 210,000 lives. I want to ensure that their health care is protected, so they can lead healthy and happy lives."
He said he had not spoken with Heller since Senate leaders unveiled their newest iteration of the legislation but hoped to have a conversation with him on Friday.
Kasich was more scathing in the statement he released before Pence spoke, saying the measure's "cuts to Medicaid are too deep and at the same time it fails to give states the ability to innovate to cope with those reductions."
"It also doesn't do enough to stabilize the insurance market, where costs are rising unsustainably and companies are simply dropping coverage," Kasich added.
Hutchinson welcomed some of the changes Senate Majority Leader Mitch McConnell, R-Ky., made to the bill after weeks of consultations with elected officials. He described "some very significant improvements to the bill," including additional funds to help middle- and lower-income Americans buy private insurance.
But in an interview after Pence's speech - and before a scheduled meeting with the vice president - he said the Senate bill remained a "deep concern" to him "in terms of the cost shift we see to the states under the reduced growth rate for Medicaid spending."
Hutchinson said he has spoken to Sen. Tom Cotton, R-Ark., "continually" about the bill, which he said is "moving in the right direction." But he said he was not ready to support it yet.
The latest draft of the bill adds $70 billion to a $112 billion state stabilization fund to be used over the course of a decade for several purposes, including helping consumers pay for insurance. It also changes the amount of funding each state receives under the Disproportionate Share Hospital program to be calculated off the state's uninsured rate, rather than its Medicaid enrollment.
Hutchinson said that he had asked for both those changes, as well as one that would allow states to include their Medicaid-expansion population in any calculations for future block grant funding of the program.
Sandoval said the stabilization fund - which Verma has been touting to Republicans from Medicaid-expansion states as a mechanism for minimizing the number of newly uninsured people - is an intriguing idea. But he was not sold yet.
"On its surface it sounds like it could be a good thing," said Sandoval. "But, you know, at the end of the day, I've got to see what it means in 2020 all the way to 2026."
Fishman's group did an analysis Friday showing that even if the entire fund was used over eight years, it would not cover insurance for the 11 million individuals who stand to lose their existing coverage. "The numbers just don't add up," he said.
Kasich, who has been working behind the scenes with both Republican and Democratic governors, criticized Senate leaders' decision to focus exclusively on passing a bill with only Republican support.
"These shortcomings flow from the fact that the Senate plan commits the same error as Obamacare - it's not bipartisan," Kasich said. "We can still fix this and repeal and replace Obamacare with ideas that will work, but it means having leaders from both sides sitting down together and working in good faith on solutions that responsibly manage Medicaid and stabilize our insurance market."
Early Saturday morning, Price and Verma will speak at a governors-only breakfast on the future of health-care. Later, White House budget director Mick Mulvaney will speak at a legislative briefing.
Asked Friday whether he could support the measure without the changes he has proposed, Ducey said, "I think they're deliberating. So let's let them deliberate."
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