Senator Dean Heller of Nevada said Friday he opposes McConnell’s plan, becoming the fifth Republican to say he won’t vote for the measure in its current form. “It’s going to be very difficult to get me to ‘yes,’” said Heller, viewed as the Senate Republican most at risk in the 2018 midterm election.

The proposal’s cuts to Medicaid and subsidies for individual insurance coverage are too tough on Nevada residents, Heller said at a news conference with Nevada Governor Brian Sandoval. Without significant changes in the proposal, the senator said he’ll vote with Democrats to block it from reaching the Senate floor.

“I cannot support a piece of legislation that takes insurance away from tens of millions of Americans and hundreds of thousands of Nevadans,” Heller said.

Related: Poll: What do you think about the GOP Senate draft of the AHCA?

Sandoval, a Republican who accepted Obamacare’s Medicaid expansion in his state, said about 210,000 Nevadans gained health coverage under the law. “They’re living healthier and happier lives because of that decision,” he said.

Wily tactician

McConnell is working to get other Republican holdouts to back the health-care bill for a possible vote next week, as he begins to separate those who can be won over with modest changes and those who may have unbridgeable concerns.

McConnell, a veteran Senate tactician, may have made some intentional omissions in the “discussion draft” he released on Thursday so that senators can be seen securing public victories in return for their support. For example, the draft contains only $2 billion for opioid-related programs, a number that could easily be boosted to win over Midwestern Republicans.

But other gaps will be much harder to overcome, particularly with conservatives demanding a fuller repeal of Obamacare and moderates uneasy about the phaseout of the original law’s Medicaid expansion.

Only a few hours after the bill was released, four conservatives led by Rand Paul of Kentucky announced they’ll need a host of changes to get to “yes.” Two moderates -- Lisa Murkowski of Alaska and Susan Collins of Maine -- said they want to remove the bill’s one-year halt in funding for Planned Parenthood. Rob Portman of Ohio said it doesn’t provide enough funds for the opioid epidemic.

“The fact we think this bill will spend more next year than Obamacare spends now, that doesn’t sound like repeal," said Paul, who added that he will be negotiating as a team with fellow conservative holdouts Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah.

‘Really special!’

President Donald Trump backed the measure in a Twitter posting that said, “I am very supportive of the Senate #HealthcareBill. Look forward to making it really special! Remember, ObamaCare is dead.”

Senator John Cornyn, the No. 2 Republican leader, said he’s still confident that at least 50 of the chamber’s 52 Republicans will wind up supporting it in a vote likely to come early next Friday morning. That’s the number needed to pass the bill, along with the tie-breaking vote support of Vice President Mike Pence.

The plan released Thursday “is sort of a best guess of where the Republican conference is,” Cornyn told reporters, adding that McConnell will massage its contents right up until when he introduces it as early as Tuesday. “But people have other things they want to see in the bill, and that’s what we’re working through.”

GOP leaders made clear "this isn’t a take-it-or-leave-it proposition," said Senator Marco Rubio of Florida.

The new bill is intended to walk a delicate line in its relatively modest tweaks to the measure that passed the House last month.

Senate leaders added funding in the first few years aimed at bringing down premiums and shoring up the Obamacare marketplaces -- an attempt to win the votes of moderates. That includes an extra $62 billion allocated over eight years to a state innovation fund, which can be used for coverage for high-risk patients, reinsurance and other items.

On the other end, it would impose longer-term austerity on health spending to appeal to conservatives. For example, in 2025, the Senate bill moves to more severe funding caps for the federal contribution to Medicaid by using the consumer price index, rather than a measure of medical inflation that tends to rise more quickly.

Over time, the extra help for states and the exchanges would phase out, and cuts to Medicaid and to insurance protections would phase in.

Premium spike

While the bill, H.R. 1628, provides far more assistance to the poor and near-poor than the House bill, it’s still substantially less generous overall than the Affordable Care Act. The biggest losers would be people at 351 percent of the federal poverty level -- a little over $42,000 for an individual -- who would go from paying a maximum 9.7 percent of their income in premiums to having no cap at all.

Related: Senate GOP health bill to break with House on key points

For older people in that income slice, the spike in premiums would be enormous, especially in higher-cost states like Alaska. A single person aged 60 in Anchorage making 351 percent of poverty is currently eligible for a $17,990 subsidy, according to the Kaiser Family Foundation’s calculator. They’d get nothing under the new plan.

The Senate, meanwhile, keeps the House’s tax cuts effectively intact -- allowing Democrats to charge that the bill finances tax cuts for the wealthy with reductions in health care.

‘Open to negotiation’

Either way, the draft is certain to undergo some changes. Some provisions may be stripped out by the Senate parliamentarian. It will also be open to amendments when it reaches the Senate floor.

The angling has already started. The joint statement by Paul and the other three conservatives said they don’t support the bill but are “open to negotiation.”

Related: AHCA continues to bring out the critics

“There are provisions in this draft that represent an improvement to our current health care system," they said in a joint statement while adding that it doesn’t "accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”

Cruz handed out a flier with his demands at a Thursday Republican caucus meeting. They included letting states design coverage without needing federal waivers, allowing consumers to buy insurance across state lines, and allowing insurers that meet federal mandates to sell other plans that don’t comply.

On the other side, Collins said she and Murkowski probably will try to strip out language defunding Planned Parenthood on the floor if leaders won’t do it.

“To single out Planned Parenthood which provides services to so many low-income women,” Collins said, “is just wrong.”

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