The future of medical coverage for over 433,000 Louisiana citizens who have joined the Medicaid ranks has become a bargaining chip in efforts to pass a U.S. Senate health care bill aimed at replacing Obamacare. Senate Majority Leader Mitch McConnell, R-Ky., needs the votes of Bill Cassidy and John Kennedy, this state’s two Republican senators.

McConnell has lost two of his 52 Republican members, and can’t afford to lose anyone else. Vice President Mike Pence would break a tie if the other 50 can be counted on to support the Senate bill.

Cassidy and Kennedy haven’t said how they will vote, but Cassidy hasn’t been happy with the Senate or House versions. Kennedy is more likely to vote for it now that McConnell has sweetened the pot.

Medicaid is the federal-state health care plan for America’s poor, but it originally offered nothing for the working poor who couldn’t afford to buy their own health care coverage. Obamacare opened up the program, but the Senate bill in its current form could eventually end the expansion in states like Louisiana.

A CNN report said more than 3 in 10 Louisiana residents are enrolled in Medicaid and the most recent Senate plan would cut Medicaid spending by 35 percent over the next two decades.

Houston Bonnyman, a New Orleans physician, in a letter to The Advocate said Medicaid in Louisiana provides essential coverage for 65 percent of all births, nearly three-fourths of frail nursing home residents, three of every five Louisiana children and is the primary source of coverage for people of all ages with severe disabilities.

The proposed Senate bill would eventually eliminate those services for many poor and low-income citizens in the state.

Bonnyman said the American Medical Association, the American Hospital Association, the American Nurses Association, the AARP, the American Cancer Society, the Children’s Hospital Association and the National Rural Health Association oppose the bill.

The Associated Press said McConnell has agreed to change two formulas to funnel more money to states that expanded Medicaid since late-2015. Democrats said the revision seemed particularly aimed at helping Louisiana.

“This unfair treatment would have cost Louisiana $2 billion in health care funding,” Kennedy told The Advocate. “This was a legitimate issue that needed to be fixed, and I’m pleased to say it has been. Now we can focus on creating a health care system that actually works.”

McConnell is cutting other deals in an effort to entice reluctant senators in other states to back his legislation.

Cassidy is a physician who has worked with many Medicaid patients at a Baton Rouge charity hospital. Like others, he knows the program isn’t as efficient as it could be and reform has been one of Cassidy’s major goals. He said he introduced comprehensive Medicaid reform called the Medicaid Accountability and Care Act and will continue to develop and promote it.

Democratic Gov. John Bel Edwards made expansion the first major goal of his administration and calls it “by far the easiest decision I have made. Through Medicaid expansion, we are bringing our federal tax dollars back to Louisiana to save lives and improve health outcomes for the working poor people of our state.”

The outcomes bear out the successes. Over 100,000 adults have received preventive health care or new patient services, over 15,000 women have been screened for breast cancer, over 10,000 citizens for colon cancer and over 25,000 have received specialized outpatient mental health services.

The full annual Medicaid expansion report can be found at www.dhh.louisiana.gov.

McConnell said he wants to vote on the Senate health care bill this week in hopes of opening up a “robust debate and robust amendment process.”

“I hope every senator will vote to open debate,” he said. “That’s how you change the status quo.”

Critics disagree and say the bill needs to be changed before it gets that far.

Cassidy has been in the forefront of this Republican effort to repeal and replace Obamacare. Unlike some critics, he has offered a number of proposals aimed at improving the legislation. He and Sen. Lindsey Graham, R-S.C., are currently working together on some of those changes.

Their proposal is modeled after the Welfare Reform Act of 1996 that was signed by then-President Bill Clinton. It ended welfare as an entitlement program and required recipients to begin working after receiving benefits for two years.

 “Our problem has been trying to combine tax reform with replacement of Obamacare,” Cassidy said. “Putting those two together has not worked.”

Whether any of Cassidy’s ideas are adopted remains to be seen, but they are definitely worth considering. He has given Louisiana a high profile in the national health care debate and won some concessions. Both have served his constituents well.