Nevada’s governor is the most important person in the Senate health care debate

The fate of the Senate Republican health care bill may rest in the hands of one man who isn’t even a member of Congress: Nevada Gov. Brian Sandoval.

On health care, he’s the most important person in the country. America’s 101st senator.

Senate Republican leaders can’t lose any more votes for their plan, a revised version of which they rolled out on Thursday. Sens. Susan Collins (R-ME) and Rand Paul (R-KY) have already said they would vote to block it. Three defectors would doom the legislation.

Now all eyes are on Sen. Dean Heller (R-NV). He vigorously opposed the original Senate proposal — and the new one doesn’t do much to address his core concerns about the $772 billion in Medicaid cuts.

Heller’s vote might not be his own. Instead, it depends on what Sandoval thinks. Heller is facing the toughest reelection race of any Senate Republican next year, and Sandoval is an overwhelmingly popular governor. Heller might have no choice but to go along with Sandoval if he plans to keep his seat.

In late June, Heller and Sandoval held a joint press conference slamming the initial Senate plan. Jon Ralston, editor of the Nevada Independent and the peerless expert on the state’s political scene, put it in absolute terms Thursday: Heller won’t vote for the bill if the governor opposes it.

Nevada has been one of Obamacare’s biggest success stories, though the law does face challenges there. Sandoval has openly embraced it. He’s already put himself out there as one of the fiercest intraparty critics of the Senate GOP’s plan.

If he holds his ground, and Heller follows suit, the Republican dream of repealing and replacing Obamacare might be dead.

Sandoval, first elected in 2010 and then overwhelmingly reelected with 70 percent of the vote in 2014, has actively worked to make the Affordable Care Act a success in his state. He was always a more moderate Republican, and Nevada had one of the highest uninsured rates in the country prior to the health care law.

He was the first Republican governor to agree to expand Medicaid after the Supreme Court made the expansion optional. He also decided to establish a state-run insurance marketplace, rather than let the federal government do everything, as most other GOP-led states did. The state ran a robust marketing campaign to encourage people to sign up last year.

The cumulative effect has been 210,000 Nevadans covered by the Medicaid expansion, according to Sandoval, and nearly 90,000 people signing up for private coverage on the marketplace, per the Kaiser Family Foundation. For a state with fewer than 3 million people, that’s a huge dent in the uninsured rate. Gallup estimated that the number of uninsured in Nevada dropped between 6.5 and 8.9 percent from 2013 to 2016, down from 22 percent in 2013 before Obamacare took full effect.

“Nevada is in a much better place than it was six years ago,” Sandoval said during his press conference in June with Heller. “I want to keep that momentum going, because your health is at the base of everything.”

Nevada, like many other largely rural states, has had some trouble keeping health insurers in its marketplace. As of right now, 14 of its most rural counties don’t have any insurance options available for next year.

But even then, the Associated Press reported that Sandoval has been working behind the scenes, writing letters and flying insurance executives into Carson City, the state’s capital, for meetings to figure out how to keep plans available in those areas.

The Republican health care bill would roll back the financial assistance for people who purchase coverage on the marketplaces, and, perhaps more importantly for Sandoval, it would eventually end the generous federal funding for Medicaid expansion and place a federal spending cap on the Medicaid program.

Medicaid spending would be cut by $772 billion over the next 10 years, compared to Obamacare, and enrollment reduced by 15 million, according to the Congressional Budget Office. The states, which administer Medicaid, would be on the hook to either increase funding to offset the spending cuts or reduce benefits and eligibility to make up for the lost federal revenue.

Sandoval was unequivocal in his June press conference with Heller.

“There was a commitment made to them,” he said of the Nevadans who had been covered by the health care law, particularly Medicaid expansion. “The current bill, as written, is something that needs to change.”

Heller, likewise, founded his objections on the Medicaid cuts. “This is all about Medicaid expansion,” he said during the press conference.

But the latest version of the Senate plan didn’t change the Medicaid provisions in any meaningful way. The enhanced federal funding for Medicaid expansion would still end, and the Medicaid spending caps would still be instituted.

Sandoval said Thursday that the plan hadn’t changed much and it “would cause me great concern,” according to the Nevada Independent.

“My staff is working very closely with [Heller’s] staff in terms of how we’re interpreting the bill,” he said.

But Senate Majority Leader Mitch McConnell (R-KY) still has some moves to make to assuage Sandoval — and, by extension, Heller. He will have some sum of money, maybe as much as $100 billion, to add to the bill while still meeting the budget standards that he must under the Senate’s procedural rules.

Axios reported Friday that Republicans are saying privately that Heller would be “bought off.”

McConnell could increase the growth rate for the Medicaid spending caps, as some health care lobbyists think he might Leadership has also tried to assure moderate senators that the deepest Medicaid cuts will never actually take effect.

Or he could try to funnel money more directly to Nevada. The current bill already includes a provision that appears designed to explicitly help Alaska, another state with wavering Republican senators. Heller told me earlier this week that there were some specific changes that could win his support.

“I’ve told them what I could live with,” he told me.

But his vote still is likely to hinge on whether Sandoval is persuaded that the Silver State will be better off.

“Nevada has to be held harmless or better off than they are today,” Heller said. “If they’re worse off, then I simply won’t support the bill.”