WASHINGTON — The 13 Republican senators who are writing a new bill to repeal and replace much of the Affordable Care Act include the top leadership, three committee chairmen and two of the most conservative members of the Senate.
What the group does not include is a woman — and the moderate Republicans who could determine the bill's fate.
The decision by Sen. Mitch McConnell of Kentucky, the majority leader, to include himself and his top three lieutenants, as well as Sens. Ted Cruz of Texas and Mike Lee of Utah — but not Sens. Susan Collins of Maine or Lisa Murkowski of Alaska, not to mention the more junior Sens. Deb Fischer of Nebraska or Shelley Moore Capito of West Virginia — has raised eyebrows.
Asked why she was not included in the Senate Republicans' health care working group, Collins said on the ABC program This Week, "Well, the leaders obviously chose the people they want."
Republicans, holding 52 seats in the Senate, can afford to lose only two members of their party on a vote to undo the health care law they have assailed for seven years. They will not receive any support from Democratic senators or the Senate's two independents, but they can count on support from Vice President Mike Pence to break a tie, if needed.
Reince Priebus, the White House chief of staff, said on Fox News Sunday that he was expecting the Senate to make "improvements where they need to be made" in the repeal bill passed last week in the House by a vote of 217-213. But Sen. Lamar Alexander of Tennessee, chairman of the Senate Health Committee and a member of McConnell's working group, went much further, suggesting the Senate is basically starting afresh.
Collins agreed. "The Senate is starting from scratch," she said Sunday.
But McConnell is likely to find the same tricky dynamic that Speaker Paul Ryan found in the difficult weeks it took to get a bill through the House: Any bill that satisfies conservatives like Cruz and Lee risks alienating many other senators, including moderates like Collins and Murkowski.
And another issue will vex Republican leaders in ways it did not in the House: Medicaid. Senators in both parties from states that have expanded the health care program for the poor have expressed strong misgivings about the House bill, which essentially unravels the expansion.
The omission of Collins has especially surprised health policy analysts. For several years starting in the late 1980s, Collins was the top insurance regulator in Maine. Early this year she introduced a bill with Sen. Bill Cassidy, R-La., that would give states much more power to reconfigure their health care systems while also preserving consumer protections in the Affordable Care Act. (Cassidy was also left off the working group.)
Conservatives mocked the Collins-Cassidy proposal, saying its basic offering to the states was that "if you like Obamacare, you can keep Obamacare."
Democrats said the Republicans' failure to include women in the working group showed that they were politically clueless. "It matters to have women at the table — and it matters when they aren't," Sen. Patty Murray of Washington said on Twitter.
Sen. Kamala Harris, D-Calif., wrote on Twitter: "The GOP is crafting policy on an issue that directly impacts women without including a single woman in the process. It's wrong."
David Popp, a spokesman for McConnell, said Monday that many Republicans were involved in devising a replacement for former President Barack Obama's health care law.
"Senators from throughout the conference have been working on solutions," Popp said. "Those meetings and efforts continue, including chairmen of the relevant committees and leadership. They will continue to have regular updates with the entire conference so the Senate can continue to move expeditiously on the work ahead as it considers the House-passed legislation."