West Virginia likes to say it's "almost heaven." Less idyllic is the spot its Republican senator, Shelley Moore Capito, is in as she decides whether to back her party's effort to bulldoze Democrat Barack Obama's health care law.
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Capito's home state has shifted strongly toward the GOP in recent years, giving Donald Trump a runaway 42-point victory over Hillary Clinton in the November presidential election. That leaves little doubt about its fondness for him and the head start Capito should have when she runs for re-election in 2020.
But it's also one of the poorest and sickest states in the U.S., relying heavily on Obama's 2010 statute, which Trump and top Senate Republicans want to repeal and replace.
West Virginia is saddled with one of the country's lowest median incomes and has some of the worst rates of unemployment, drug overdose deaths, life expectancy, smoking, obesity, diabetes, heart disease, cancer and disabilities. Around 3 in 10 of the 1.8 million West Virginians are on Medicaid, making it the most dependent state on the health insurance program for the poor, disabled and nursing home residents that the GOP bill would cut.
"I didn't come to Washington to hurt people. Health care is something I care deeply about," Capito said in an interview. But she added, "I do think changes and reforms in Medicaid are necessary. We can't have an open pocketbook."
Her stance has attracted the attention of liberal, labor, patient and provider groups, who are using social media, advertising and demonstrations to pressure Capito. A recent sit-in at her Charleston office led to six arrests.
Fellow Sen. Bernie Sanders, I-Vt., who easily carried West Virginia's Democratic presidential primary last year, is headlining a health care rally in the state on Sunday. The Progressive Change Campaign Committee ran a TV ad featuring the mother of a grown daughter with cerebral palsy saying she "wants to cry" when she hears Capito may support Medicaid cuts, and liberal MoveOn.org, the state AFL-CIO and others are using #savemecapito on Twitter to whip up opposition to the GOP bill.
And while aides say she's held numerous meetings with constituents, advocacy groups and local officials, like many Senate Republicans, she avoided this week's July 4 parades — normally a staple of politicking— and skipped town halls this year.
"So far, she's been a person of ethics and morals to try to do the right thing for West Virginians," said Debrin Jenkins, executive director of the West Virginia Rural Health Association, which advocates for health care in the state's many small communities. Jenkins said the GOP bill would "gut" affordable health coverage in West Virginia.
An amiable and popular moderate in Congress since 2001, Capito is a devoted coal industry defender and daughter of former three-time Gov. Arch Moore. With her most serious re-election threat perhaps posed by a conservative in the GOP primary, many consider her a team player unlikely to help derail a paramount Republican goal like toppling Obama's law.
"I think she's going to vote for it eventually. I think there's going to be a few things in there that would allow her to say she's protecting West Virginia," said Simon Haeder, a political science professor at West Virginia University.
Yet Capito, 63, was one reason the Senate left town last week for the July 4 recess without voting on GOP legislation scrapping the law.
She was among at least a dozen Republican senators who publicly opposed or expressed qualms about it, forcing Majority Leader Mitch McConnell, R-Ky., to avert defeat by abruptly postponing the vote. Unyielding Democratic opposition means the bill loses if just three of the 52 GOP senators vote no, and McConnell is spending the break proposing changes and gauging support.
Capito said she was against the GOP bill, though she announced that after McConnell withdrew the initial measure. She said it cut Medicaid too deeply, would hurt rural providers and shortchanged efforts to combat the abuse of drugs like opioids, a deadly scourge back home.
She says McConnell's plans to add $45 billion over a decade for states' drug abuse programs is a plus, and she wants the bill's federal health care subsidies geared toward helping the state's rural, poor and often older residents.
And she wants some way to protect the state's Medicaid expansion, which has added 175,000 beneficiaries to the program. More than a fourth have substance abuse problems, and state officials say they got $112 million in federal money last year to provide services for them.
"I'm not interested" in having them "dropped out of the system," she said.
"There are tweaks than can happen that would ultimately gain her support," said state GOP chairman Conrad Lucas, a former Capito aide. He said she has nothing to fear from Trump voters because she simply favors repealing Obama's law with a replacement that's "in the best interests of West Virginia."
Under Obama's law, the state's percentage of uninsured people has dropped to 6 percent, half the 2013 figure before the statute took full effect. Thanks to Medicaid expansion, West Virginia's program has around 525,000 beneficiaries overall and gets $2.8 billion in federal Medicaid assistance each year.
The Senate GOP bill would phase out the extra money West Virginia and other states get for the Medicaid expansion. It also would turn the program, which currently pays states for all eligible services, into one with a dollar cap that increases only with inflation.
That would be tough, according to a report by the Urban Institute and Robert Wood Johnson Foundation, two nonpartisan groups. They estimated that by 2022, the measure would boost West Virginia's uninsured rate to 20 percent and halve its Medicaid enrollment.
"It will result in pockets of people with poverty and lack of access who won't be able to afford insurance but still have health problems," said Dr. Rahul Gupta, the state's public health commissioner and Democratic appointee.
"I hope she's able to, and I think she will, she'll make a good decision here," said her West Virginia colleague, Democratic Sen. Joe Manchin.
Fram reported from Washington.