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Senator Dean Heller, right, and Nevada Governor Brian Sandoval speak with media inside the Grant Sawyer State Office Building in Las Vegas on Friday, June 23, 2017. (Daniel Clark/The Nevada Independent)

It was in late June, just a day after Senate Republicans’ released their plan to repeal and replace the Affordable Care Act, that Republican Sen. Dean Heller held up a copy of the 147-page proposal and declared that it was “simply not the answer.”

Flanked by popular Gov. Brian Sandoval, also a Republican, Heller rattled off a laundry list of the ways in which the legislation was bad for Nevada. It didn’t protect the most vulnerable Nevadans, the cuts to Medicaid threatened critical services, it would mean a loss of coverage for millions of Americans and — to top it off — he wasn’t confident that it would lower health care costs.

Not only did he oppose the legislation, he said that he would oppose a procedural motion that would allow the Senate to proceed to debate on the issue.

“If this is the bill that I’m voting for on Tuesday in the procedural motion to move ahead, I will be voting no,” Heller said.

A little more than a month later, with no plans on the table he appeared comfortable supporting, Heller voted to do the opposite -- he voted for a motion to debate a bill. He said he did it in the hope that the final product would be improved and something he could support; if it wasn’t, he would vote it down.

"Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” Heller said in a Tuesday statement announcing his vote. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans  — particularly those living in rural areas — with dwindling or no choices.”

But then on Thursday, with no sand left in the hourglass, Heller voted without explanation to pass what was termed a “skinny repeal” of the Affordable Care Act, essentially removing the so-called individual mandate for people to purchase insurance and employer mandate requiring companies to buy their workers insurance, as well as extending a moratorium on a medical device tax. It included other provisions increasing the amount a person can contribute to a health savings account and, for one year, barring federal funds from going toward organizations that provide abortions — a move to defund Planned Parenthood.

Many Republican senators justified their votes in favor of skinny repeal by saying that it was just a vehicle to get lawmakers from the House and Senate to a conference committee to hash out a final, compromise health care bill. But when he finally explained his vote the following afternoon, Heller seemed actually supportive of the skinny repeal concept as a whole.

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” Heller said in a statement to the Las Vegas Sun on Friday. “While not perfect, the Health Care Freedom Act protected coverage for our most vulnerable and provided relief to many hard-working Nevadans by repealing the most onerous provision of Obamacare, the individual mandate.”

A spokeswoman for the senator did not respond to multiple requests for comment seeking additional information about Heller’s skinny repeal vote on Friday.

Though the skinny repeal did not touch the Medicaid expansion funds Heller sought to protect for the roughly 210,000 Nevadans covered by them, the nonpartisan Congressional Budget Office estimated that the skinny repeal would result in 15 million Americans losing insurance and premiums that are 20 percent higher than they are. Heller’s statement did not address the dissonance between voting for the skinny repeal and Heller’s statement made at that press conference in late June that he wouldn’t support a bill that resulted in millions of Americans losing insurance.

“Barring significant changes from the Congressional Budget Office, this bill will mean a loss of coverage for millions of Americans and many Nevadans,” Heller said in June. “I’m telling you right now I cannot support a piece of legislation that takes insurance away from tens of millions of Americans and hundreds of thousands of Nevadans.”

But Heller’s role in the health care fight might not be over yet. The Nevada senator, South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy met with the president at the White House on Friday about their proposal to block grant existing federal health care funds to the states while keeping in place the taxes created by the Affordable Care Act, according to Politico. It is unclear exactly how the measure would affect Nevada’s Medicaid population, though one liberal think tank has estimated that it would significantly slash federal dollars to the program.

If Republicans can come to an agreement about a new path forward, the Senate could reopen debate on the health care legislation as early as next week.

Declaring opposition

Heller has long opposed the Affordable Care Act, voting against it back in March 2010 when he was Congressman Heller representing Nevada’s 2nd District. When Republicans took control of the House the spring of 2011, he voted several times to repeal or tweak portions of the federal law before being appointed in May by Sandoval to fill John Ensign’s Senate seat.

His fifth press release after joining the Senate was titled “Obamacare Will Not Work for Nevada.”

“It is clear that the unique health-care needs of individual states were not taken into consideration, and this is why Obamacare will not work for Nevada,” Heller said. “This DC bureaucrat-driven health care system will only result in limited health care choices and higher costs for Nevadans.”

Heller voted in favor of a clean Affordable Care Act repeal bill in 2015, which President Barack Obama ultimately vetoed. The legislation didn’t repeal the law in its entirety, but it would have phased out subsidies given to low and middle-income individuals to help them afford insurance on the health care exchanges, eliminated tax penalties for individuals and employers who don’t purchase or provide health insurance plans and eliminated taxes on medical devices and the “Cadillac tax” on high-cost, employer-sponsored health plans.

Importantly, the 2015 bill would have phased out an expansion of Medicaid over a two-year period. The Affordable Care Act initially required states to expand their Medicaid programs to fill historical eligibility gaps by providing coverage to all low-income individuals who make at or below 138 percent of poverty, later made optional by a 2012 U.S. Supreme Court ruling.

Nevada was one of 31 states that opted into Medicaid expansion, with more than 640,000 Nevadans today relying on the joint federal and state assistance program that provides health coverage to children, pregnant women, seniors, the disabled and low-income individuals across the country. About a third, or 210,000 of those, are specifically part of the Medicaid expansion population.

Sandoval was the first Republican governor in the United States to opt-in to the Medicaid expansion, his decision hinging on the potential savings to the state in mental health spending and getting the state’s diabetic population access to the preventative care they needed to avoid costly emergency room visits.

In the wake of Medicaid expansion, Nevada has essentially restructured the way it provides mental health services by shifting away from state-funded services toward private providers who are paid with federal Medicaid dollars. The state’s uninsured rate dropped from 22 percent in 2012 to 12 percent in 2015, with the number of uninsured children dropping from 14.9 percent in 2012 to 7.6 percent in 2015.

“Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court,” Sandoval said in a statement announcing Medicaid expansion. “As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage."

That’s why, at that press conference last month, Sandoval promised to fight to continue insurance coverage for the Medicaid population, saying that he felt he had made a “personal commitment” to them.

“These are the people that I’ve talked about, these are the people I have fought for in the last three years,” he said. “Nevada is in a much better place than it was six years ago, four years ago, even two years ago. And I want to keep that momentum going because your health is the base of everything.”

And that’s why, at that June press conference, Heller stood next to Sandoval and promised to vote against a bill that stripped Medicaid funding away from Nevada. The state estimated that rolling back Medicaid expansion would have left a $420 million budget hole, which would have left the state to cut services, eligibility or reimbursement rates or else raise taxes.

“I’ve always said the same thing — if you want my support, if you want my support on legislation on health care that fixes the state of Nevada that supports these people that are on expanded Medicaid then you’ve got to make sure that the Republican governors that have expanded this Medicaid sign off on it,” Heller said in June. “I’ve been saying that for months, and some of you have quoted me on that. What does Governor Sandoval think? What does he think? How does he feel about the changes that are occurring?”

With moderate Republicans such as Heller, Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins expressing serious reservations about the bill’s cuts to Medicaid and conservative Republicans, including Kentucky Sen. Rand Paul, Utah Sen. Mike Lee and Texas Sen. Ted Cruz, saying the bill didn’t go far enough, Senate Republicans returned to the drawing board.

A second draft

When the second version of the Senate’s health-care bill came out on July 13, Heller was mum. He told Politico that he wouldn’t make a decision on the legislation “until I read the bill — that’s what I’m doing this weekend.”

The bill kept in place a repeal of the individual mandate requiring people to purchase health insurance and made extensive cuts to the Medicaid program. But it also contained a number of altered and new provisions, including billions to combat opioid addiction and additional funding to help pay for state-based reforms — as well as an amendment from Texas Sen. Ted Cruz that would allow insurance companies to offer higher deductible plans so long as they offer one ACA-compliant plan.

The day the bill text was released, Sandoval said that the legislation didn’t seem much different than the first version and said it would cause him “great concern.” And though the senator had seemingly tied himself to the governor on the health care issue with their June appearance, Sandoval said he’d leave the decision-making on the bill up to Heller.

“I’ll leave it to Heller on what he’s going to decide what he’s doing on process,” Sandoval said. “My staff is working very closely with his staff in terms of how we’re interpreting the bill.”

While Heller weighed his decision on the bill over the course of a few days, Collins and Paul announced the day the bill came out that they would vote “no” on a motion to proceed to debate on the legislation. The following Monday, four days later, Kansas Sen. Jerry Moran and Utah Sen. Mike Lee said they would also not support a motion to take the bill up, effectively sending it to its grave.

Two days later, Senate Majority Leader Mitch McConnell announced that the Senate would instead take up a bill just to repeal the Affordable Care Act, modeled off of the 2015 legislation that Heller voted to support. But it was unclear what path the legislation would have to move forward, with Murkowski, Collins and West Virginia Sen. Shelley Capito all in opposition to a motion to proceed.

The same day, a Wednesday, President Donald Trump invited senators to a lunch at the White House to talk about health care. He goaded Heller, who sat next to the president, over his wavering position on health care.

“Look, he wants to remain a senator, doesn’t he? And I think the people of your state, which I know very well, I think they’re gonna appreciate what you hopefully will do,” Trump said. “Any senator who votes against starting debate is really telling America that you’re fine with Obamacare. But being fine with Obamacare isn’t enough for another reason. Because it’s gone. It’s failed. It’s not gonna be around.”

It wasn’t until several days later, Monday, that McConnell confirmed that the chamber would take up a procedural vote on Tuesday to begin discussion on the version of the health care bill passed by the House, the AHCA or the American Health Care Act, in order to bring forward the Senate’s proposals. But it was still unclear what version of a health care bill Senate Republicans would bring up or whether they’d even have enough votes on a motion to proceed.

Twenty hours of debate

The morning of the procedural vote to start debate on the health care legislation, Heller still had yet to declare how he would vote on the motion. It wasn’t until right before the procedural vote was scheduled to happen that he made the announcement — he would vote in favor of the motion.

“I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices,” Heller said in a statement minutes before the vote. “Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either.”

The motion to proceed to debate passed by the thinnest of margins, 51-50 with only Collins and Murkowski joining Democrats in opposition and Vice President Mike Pence as the tie-breaking vote. Sens. Ron Johnson of Wisconsin and John McCain of Arizona cast the final two Republican votes in support of moving forward with debate on the health care legislation.

In a dramatic move, McCain had returned to the Senate Tuesday to push the measure forward after a surgery and recently being diagnosed with brain cancer. In a speech on the Senate floor just after the vote, McCain urged his colleagues to return to “regular order” in the Senate and move forward with health care discussions in a more transparent, deliberative process.

“Let's trust each other. Let's return to regular order. We've been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle,” McCain said. “That's an approach that's been employed by both sides, mandating legislation from the top down, without any support from the other side, with all the parliamentary maneuvers that requires.”

But a few hours later, when it came time to vote on the Senate’s repeal and replace bill, Heller voted against the measure.

The version of the bill the Senate voted on Tuesday night, which failed 43-53 after needing 60 votes to proceed, included many of the original elements of the original proposal with Cruz’s amendment and a proposal from Ohio Sen. Rob Portman to add an additional $100 billion to help cover out-of-pocket costs for some Medicaid patients. The nonpartisan Congressional Budget Office estimated that an earlier version of the bill would have resulted in 22 million Americans losing insurance.

Then, Heller and six of his Republican colleagues joined Democrats to also reject the repeal-only bill mirrored off of the bill he voted in 2015 to support. The bill, which failed 45-55, would have eliminated individual and employer mandates, marketplace subsidies, the exchanges and taxes on the wealthy and health-care industry in two years and kept in place protections for people with pre-existing conditions.

That left one final option for Senate Republicans who hoped to pass something to send back to the House in order to continue discussions in a conference committee and hopefully reach final consensus on a bill — the skinny repeal. Heller said on Wednesday that he wanted to see what was in the final version of the skinny repeal but that “overall I think I’d support it.”

But then Sandoval, in a letter to McConnell and Senate Minority Leader Chuck Schumer signed by nine other governors, declared their opposition to a skinny repeal on Wednesday, urging the Senate to return to regular order and work toward a bipartisan compromise on health care.

“The Senate should also reject efforts to amend the bill into a ‘skinny repeal,’ which is expected to accelerate health plans leaving the individual market, increase premiums, and result in fewer Americans having access to coverage,” the governors wrote. “Instead, we ask senators to work with governors on solutions to problems we can all agree on: fixing our unstable insurance markets.”

Heller also on Wednesday introduced an amendment that would have expressed the Senate’s support for protecting Medicaid funding even as it considered a repeal of the Affordable Care Act. It died in an overwhelming 10-90 vote with opposition from Republicans who would actually like to see cuts made to the program and from Democrats who want to see the ACA left intact.

On Thursday morning, with the skinny repeal vote looming, Heller signed onto an amendment put by Graham from South Carolina and Cassidy from Louisiana to keep in place most of the taxes from the ACA but send the money raised from those taxes to the states in the form of block grants. Heller called the amendment “the most conservative and workable solution” in announcing his support for the proposal.

According to an analysis by the left-leaning Center on Budget and Policy priorities, the measure would have left block grant funding in 2020 at $26 billion, 16 percent below projected levels of federal funding for Medicaid expansion and marketplace subsidies and slashed Medicaid dollars through the implementation of a per capita cap on funds states receive. The amendment never received a vote on Thursday.

As a final last-ditch effort, Heller put forward an amendment to repeal the ACA’s so-called Cadillac tax on high-cost, employer-sponsored health insurance, something the Republican senator has long championed along with Democratic Sen. Martin Heinrich from New Mexico. It was the first measure to succeed in three days of debate, passing the Senate in a 52-48 vote with only Heinrich and Heller’s Democratic counterpart Sen. Cortez Masto joining Republicans in support.

Early Friday morning in Washington, after 20 hours of debate, it was finally time for the Senate to take its final votes. First, a final attempt by Democrats to send the legislation back to committee for consideration, followed by the skinny repeal vote.

The first vote had no chance of succeeding, and yet even when it was clear the motion had failed 48-52, the rolls remained open as senators conferred on the senate floor in an attempt to secure last-minute votes on the skinny repeal. Heller conferred with Pence, McConnell, South Dakota Sen. John Thune and Arizona Sen. Jeff Flake.

But it appeared to be McCain, Murkowski and Collins who were the focus of attention. At one point, McCain talked with a group of Democrats and was hugged by California Sen. Dianne Feinstein.

Finally, the roll on the first vote closed, and the skinny repeal vote began. In the first pass, Collins, Murkowski and McCain cast their votes against the measure; by the time Heller cast his “yes” vote, it was already dead.

Though the hope of finding a path forward for the health care bill seems dimmer than ever, Trump met with the Graham-Cassidy-Heller amendment’s eponyms on Friday in an attempt to write a bill that could get the support of 50 Republican senators. Though the bill has not yet been scored by the Congressional Budget Office, supporters of the proposal have told the White House that the bill will score better than previous proposals, Politico reported.

But with McCain in Arizona for cancer treatment until the end of the August recess, Republican leadership would need the support of either Collins or Murkowski to re-open debate on the legislation.

***

The unknown is what kind of an impact Heller’s votes will have on his chances of re-election in 2018. He is considered the most vulnerable Republican senator and already has a foe in Democratic Rep. Jacky Rosen, recruited by Reid to challenge Heller for his seat.

Rosen wasted no time on Friday hammering Heller for supporting the skinny repeal, calling it the “biggest broken political promise in modern Nevada history.”

“Last month, Senator Heller promised that he could not vote for legislation that takes away insurance from tens of millions of Americans and hundreds of thousands of Nevadans. Last night, he voted to do just that,” Rosen said in a statement. “No politician from our state has ever been more dishonest about their intentions, more misleading about their position or more disingenuous to their constituents.”

Though Heller’s vote has drawn the ire of Democrats, some Republicans in Nevada have remained unhappy with him for his fluctuating positions on health care. The Republican National Committee put out a statement on Friday applauding Heller on the issue in an attempt to remind people of Heller’s conservative bona fides.

“Senator Heller understands that Obamacare is failing the hard working people of Nevada and that the status quo is no longer acceptable,” said RNC spokesperson Christiana Purves in a statement. “We applaud Heller for his dedication to finding a solution to our health care system that ensures Nevadans have access to affordable health care, and repeals the burdensome individual mandate.”

Sandoval, who could be Heller’s biggest ally in his re-election fight, indicated on Friday that he hopes that Congress will involve states in their ongoing conversations over how to improve the nation's health care system.

“There's bipartisan agreement that the ACA is not perfect and needs to be fixed,” his office said in a statement. “Governor Sandoval, along with his fellow Governors, has offered throughout this debate to engage with Congress on reforms to the health care market, and that offer still stands.”

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