U.S. Rep. Elise Stefanik, R-Willsboro (Photo provided by Rep. Elise Stefanik)

WASHINGTON — The fate of the Republican health-care plan appears to rest on conservative Republicans like Rep. Lou Barletta of Pennsylvania and centrists like Rep. Elise Stefanik of New York.

Barletta, an immigration hard-liner, said he remains opposed to the legislation because it lacks sufficient verification safeguards against subsidies to illegal recipients.

Stefanik said she wants to repeal the Affordable Care Act but isn’t ready yet to embrace the GOP replacement, even though an amended version of the bill exempts the rural counties that she represents from helping fund state Medicaid costs.

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Vote looms

President Donald Trump, Speaker Paul Ryan and other Republican leaders spent this week on Capitol Hill trying to round up the 216 House votes needed to approve the bill in a showdown vote expected Thursday and send it to the Senate.

Trump urged Republican to unite or face voter backlash, predicting, “We’re going to get a winner vote.”

Ryan said the president “knocked the ball out of the park” in his meetings with the GOP lawmakers.

The GOP holds a 237-to-193 edge over Democrats in the House, but several conservative and moderate Republicans have indicated resistance — for vastly different reasons.

The conservatives say the bill doesn’t go far enough in repealing present law, and the moderates fear it will balloon the number of uninsured Americans by several million.

Democrats, to a member, say they will have no part in voting for a bill that would dismantle former President Barack Obama’s signature legislative achievement.

The chief executive officers of all the hospitals in the North Country have come out in opposition to the GOP plan.

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Medicaid exclusions

Ryan tried to woo upstate New York Republicans, including Stefanik, who represents Clinton, Essex and Franklin counties as part of the 21st Congressional District, with an amendment to the GOP health bill that would exclude rural counties from having to contribute to the state’s Medicaid expenses.

The federal government covers half of Medicaid expenses, and New York is one of the only states that requires counties to pay part of its share. It used to split its share evenly with counties, but since the counties’ share was capped in 2005 and more strictly in 2012, the state picks up the annual increases. Stefanik and other moderate Republicans met later in the day at the White House with Vice President Mike Pence and Reince Priebus, Trump’s chief of staff.

Rural counties have complained they are strapped for cash and that requiring them to help pay for New York’s Medicaid expenses forces them to raise property taxes that homeowners can’t afford.

An analysis by Rep. John Katko, R-N.Y., said counties outside New York City contributed $2.2 billion, including $17 million from Clinton County and $6.9 million from Essex County.

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Locals interested

Medicaid has long been a high-cost program for counties in New York. In some, the program accounts for as much as 80 percent of the tax levy. In Clinton County, Medicaid makes up 62 percent of the tax levy. In Essex County it’s 32 percent.

Essex County Manager Dan Palmer pointed out that Medicaid is far from the only service counties are mandated to partly pay for, although it is the single biggest. From probation to preschool to foster care to public health, Palmer said roughly 85 percent of Essex County’s tax levy is mandated by the state and to a lesser degree federal governments. If the state is forced to pay for all of Medicaid, Palmer worried it might compensate by cutting in those other areas.

“We don’t know where the other shoe would drop,” he said.

Clinton County Legislator Mark Dame (R-Area 8, city and town of Plattsburgh), who chairs the county’s Finance Committee, said the proposed amendment to the federal health-care bill would be a significant transformation for county government.

“It (Medicaid) is an unfair program, and it needs to be changed, and if this health-care bill fixes it, then I’m all for it,” Dame said.

Dame said forcing the state to take over the program without the aid of county dollars might make them run it more efficiently.

“There is way too much fraud in this program, and the state would have to come up with a much more efficient way of running it,” he said.

Clinton County Administrator Michael Zurlo said they are paying close attention to the Medicaid idea.

“This is an intriguing proposal, and the county is taking a hard look at it,” he said.

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“Deathtrap”

New York Democrat Gov. Andrew Cuomo criticized the Republican amendment to exempt rural counties that have fewer than 5 million residents. He called it a “deathtrap” that would cost the state $2.3 billion annually — if the state covers it at all.

“The cut is so severe that the majority of hospitals, nursing homes and assisted-living facilities located in Upstate New York and on Long Island would be devastated,” Cuomo said.

Patrick Nelson, a Democrat from Saratoga County running an early campaign against Stefanik for the 2018 election, disagreed with Cuomo about the state picking up Medicaid costs but still opposes the GOP plan.

“The idea of shifting Medicaid away from the counties in NY is a good one, but it is one that should be handled by the State and not forced upon it by the Federal Government,” Nesleon said in a written statement. “This is just another example that all this talk from DC Republicans about being against government overreach is just that, talk.

“The amendment also does nothing to fix a fundamentally broken, dangerous, and misguided proposal that will risk the lives of our neighbors to provide large tax breaks for a privileged few.”

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Enterprise Managing Editor Peter Crowley contributed to this report.

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(Editor’s note: Four daily newspapers in the North Country — the Enterprise, Post-Star of Glens Falls, Watertown Daily Times and Press-Republican of Plattsburgh — are sharing content to better cover New York’s 21st Congressional District.)