WASHINGTON — Pressure mounted Monday on Alaska's two Republican senators as they prepared to take a vote on repealing — and potentially replacing — the Affordable Care Act Tuesday, without knowing which bill would be the subject of their vote.
The likely vote of Alaska's senior Sen. Lisa Murkowski, in particular, has been the focus of political curiosity as a possible swing-vote.
Much of the visible pressure on lawmakers, such as call-in campaigns and advertisements, has been from pro-Obamacare forces. But Republican lawmakers are facing enormous pressure from within their own party to stick to the promises uttered over and again for the last seven years.
Murkowski and Sen. Dan Sullivan heard the same message over the last several days from the head of the Alaska Republican Party, Tuckerman Babcock, President Donald Trump and Senate Majority Leader Mitch McConnell, R-Ky.: You promised to repeal Obamacare; now do it.
[Trump pleads with Republicans to roll back Obamacare]
Republicans have kept the plans a party-line affair, and can only afford to lose two votes, to pass a bill.
But whether Murkowski and Sullivan would vote for any repeal and replace bill offered up this week remains unknown, as negotiations head through fits and starts, and both senators remained unsure what bill would come up on the Senate floor Tuesday.
In a letter to both lawmakers this weekend, Babcock sought to remind them of the promises made to Alaska Republicans.
"I recognize that it is the job of those we elect to administrate and legislate. I respect those spheres of responsibility and fully appreciate that the complexity of crafting and amending legislation is your responsibility and not that of the Party," Babcock said in the letter.
"However, there are times when a specific issue is so central to our message, to our platform and to our promises to voters that I am persuaded a public statement from the Alaska Republican Party is warranted," he said.
Since 2010, repealing the ACA has been central to the GOP's message to voters, Babcock said. "The integrity of our mutual promise, our united message and our platform could not be more direct or more clear," he wrote.
In an interview Monday, Babcock said he just could not imagine a situation where voters granted Republicans control of the U.S. House, Senate and White House, and the party failed to follow through on repealing the ACA.
Babcock said he was not attempting to weigh in on what Congress should do to replace the law and he hoped for a bipartisan effort.
But "I think it would be a true mark of failure on the Republican Party nationally and in Alaska" to fail to repeal the law, he said. "You can't have something be your central promise election after election after election" and fail to do it, Babcock said.
That same message came from a lectern in the White House Monday afternoon, as the president spoke on the subject of repealing the ACA.
"Remember: Repeal and replace, repeal and replace. They kept saying it over and over again. Every Republican running for office promised immediate relief from this disastrous law," Trump said Monday.
Republicans "must fulfill that solemn promise to the voters of this country to repeal and replace — what they've been saying for the last seven years," Trump said.
"Any senator who votes against starting debate is telling America that you are fine with the Obamacare nightmare, which is what it is," he said.
McConnell took to the Senate floor Monday afternoon and echoed that statement.
The majority leader urged his colleagues in the Senate to vote "yes" on beginning debate on a bill to repeal the law.
"That means voting to begin the open amendment process. That means voting to kick off a robust debate in which Senators from all parties can represent the views of their constituents. It means voting to proceed. And that will occur tomorrow," McConnell said Monday.
But Murkowski and Sullivan weren't only hearing political pressure from the party Monday. A slew of health care organizations and companies urged caution, and questioned the quality of the bills offered.
Becky Hultberg, president of the Alaska State Hospital and Nursing Home Association, said Monday that group remains "deeply concerned about both the process and policy" that led to the Senate's planned Tuesday vote.
The proposals would result in "higher health care costs for Alaskans, even for those covered with employer-based insurance, and fewer Alaskans with health insurance. From what we know, the proposals would also be devastating for Alaska health care providers. This is bad policy and it would move Alaska in the wrong direction," Hultberg said.
Moreover, Hultberg criticized the process by which the Senate crafted its bills, behind closed doors and without the transparency of a public committee process. Murkowski has made that argument regularly over the last month.
There are several options for a vote Tuesday.
The Obamacare Repeal Reconciliation Act — already passed by the Senate in 2015, but vetoed by President Barack Obama, would repeal the law starting in two years.
That would, presumably, give Congress two years to come up with replacement measures. Both Murkowski and Alaska Sen. Dan Sullivan voted for the bill in 2015.
But it's a nonstarter for Murkowski now, she said last week. Murkowski, worried about the prospects of undoing Medicaid expansion and other provisions of the law without a plan for replacement, said she would vote no on a motion to proceed with debate on that bill.
Sullivan said he would vote yes on the bill, as he had in 2015.
[Here's what happens in Alaska with a straight repeal of the Affordable Care Act]
The Senate could also vote to start debate on some version of the Better Care Reconciliation Act, the Senate's current repeal-and-replace effort.
Neither Murkowski nor Sullivan has clearly stated whether they would vote for the bill. The senators did secure Alaska-focused funding in the latest version of the bill, but both said they have remaining concerns about how the bill would impact Medicaid in Alaska.
The Senate could also take a vote on a bill that hasn't had much discussion in recent weeks: the repeal-and-replace bill that passed the House in May, the American Health Care Act.
Neither Murkowski nor Sullivan has expressed a recent opinion on the House-passed bill, but Alaska's lawmakers offered up concerns with its disproportionate impact on Alaska when it was passed.
Murkowski said she didn't get the sense that the bill was built on "good policy," but instead through an effort "to find votes."
Alaska's Republican Rep. Don Young voted in favor of the bill, but said he did so with promises that it would be a starting point for negotiations, and the bill would never make it to the president's desk in its current form.
"I've talked to the Secretary (of Health and Human Services) — Dr. (Tom) Price — and he assures me that (Alaska) will be made whole, if it was to become law," Young said at the time.
[How Don Young went from no to yes on the House health care bill]