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The acrimony between President Donald Trump and Arizona Republican Jeff Flake, which is already making the senator’s re-election bid more challenging, should only intensify during the president’s rally in Phoenix on Tuesday night.

Flake is known as a Trump opponent, which could make him vulnerable in the primary. The feud appeared to start in a private meeting a year ago, but has since escalated. Earlier this summer, Flake published a book, titled “Conscience of a Conservative,” publicly criticizing the Republican Party for the rise of Trump.

While the senator gained some admirers for being so outspoken against the president, he has also drawn criticism from certain elements in the GOP. Flake has at least one primary opponent, former state Sen. Kelli Ward, who lost a primary challenge to Sen. John McCain 51 percent to 40 percent last year. Trump praised her candidacy in a tweet last week, and one of his key donors contributed $300,000 to a PAC to defeat Flake.

Flake could also face a credible Democratic opponent in the general election, if he survives the primary. State Rep. Randy Friese, the doctor who assisted Rep. Gabrielle Giffords in the 2011 shooting in Tucson, Arizona, is seriously interested in running. But he could be joined in the race by Rep. Kyrsten Sinema or Phoenix Mayor Greg Stanton.

Democrats will gladly point out that Flake, in spite of his reputation, has voted for much of Trump’s agenda (over 93.5 percent, according to FiveThirtyEight), including the recent health care proposal, for which McCain was the deciding “no” vote. That could make Flake vulnerable in the general election. If Flake is going to win re-election, he can’t afford too many defections from Republicans who are more loyal to Trump. And he doesn’t have a lot of room for error.

In 2012, Flake was elected to GOP Sen. Jon Kyl’s open seat with a 49 percent to 46 percent victory over Democratic former U.S. Surgeon General Richard Carmona. In that race, Flake won both Republicans, 90-6 percent, and independents (albeit narrowly, 46-45 percent), according to the exit polls.

A recent Public Policy Polling survey showed Flake with a 22 percent job approval rating among 2016 Trump voters, while 63 percent of them disapproved. It was an automated poll by a Democratic firm, but those numbers should be alarming for the senator and his allies.

At a minimum, Ward’s primary challenge will make it harder to unite the party. That’s important in Arizona considering the primary is late in the cycle — Aug. 28 — leaving little time to reunite the party between a likely bitter primary and the general election. Flake will likely need to dramatically improve among independents and/or Democrats in order to compensate for some lost or missing Republicans whose loyalties lie first with the president.

With Flake’s significant risk of losing voters on both sides of the ideological spectrum, we’re changing the Inside Elections rating of the Arizona Senate race from Leans Republican to Tilts Republican, a move in favor of the Democrats.

Considering Hillary Clinton won Nevada, Sen. Dean Heller is still the most vulnerable Republican incumbent in the country. But that doesn’t mean Flake isn’t too far behind. Both seats are important to Republicans’ ability to hold and expand their majority next year.

You can read more complete analysis for the Arizona Senate race in the Aug. 18 issue of Inside Elections.

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When House Republicans passed their measure to repeal and replace the 2010 health care law in May, 20 members of their conference voted against it.

While some of them might be able to defend themselves against criticism by saying they voted against a historically unpopular bill, they could find themselves in the same political peril as Democrats who voted against the original health care bill in 2010.

An analysis by Roll Call found that of the 34 House Democrats who voted against the legislation signed by President Barack Obama in 2010, 17 lost in the midterm elections later that year.

Two more lost in 2012, and another two lost in 2014. And none who ran for higher office, such as for governor or Senate, won. Others have since left office.

Former Kentucky Rep. Ben Chandler, who lost to Republican Andy Barr in 2012, said health care didn’t show up in his opponents’ campaign ads.

“That being said, that doesn’t mean it wasn’t a factor. It created a great deal of the atmosphere,” Chandler said.

The atmosphere at the time was toxic, with angry constituents screaming at their elected representatives at town hall meetings, leading to an anti-Democratic wave which saw the GOP take back the House — much like the anger directed at Republicans this summer.

Chandler said health care votes are polarizing by nature.

“Any party that grabs onto health care is grabbing onto pure political poison,” he said.

Former Ohio Rep. Zack Space, who lost in 2010, said he voted against the final legislation because it lacked the public health care option that was in the original legislation.

My concern was the bill needed a mechanism to keep costs down. I felt the public option was the way,” said Space, who is running for state auditor in Ohio this cycle.

Space said whether he voted for the bill or not, it wouldn’t have helped his chances in the midterms.

“Frankly, the party brand was compromised as a result of the legislation, than me individually,” he said. “I think I got caught up in a wave.”

Only three Democrats who voted against the 2010 bill are still in office: Collin C. Peterson of Minnesota, Daniel Lipinski of Illinois, and Stephen F. Lynch of Massachusetts.

Peterson said he does not regret his vote, even though Republicans have tried to use his subsequent votes against repealing it against him.

“This was always a political ploy. They used it against me,” he said. “I didn’t vote to repeal it, either, because we would have repealed those needed changes.”

Roll Call reached out to a number of vulnerable Republicans, up for re-election next year, who voted against the repeal bill, but none responded to our inquiries.

Of the 20 Republicans who voted against the GOP health care bill, eight are facing competitive re-election races, according to Inside Elections with Nathan L. Gonzales, including Texas Rep. Will Hurd, whose contest is rated a Toss-Up.

Rep. Ileana Ros-Lehtinen, who voted against the bill, is leaving Congress at the end of this term. But that didn’t affect her vote, the Florida Republican said.

“If I had chosen to run again, I would have voted the same way because the impact of the ACA repeal bill is the same regardless if my name appears on the ballot,” she said.

But a former GOP operative who was involved in the 2010 midterm elections said health care is only one of the issues on which Democrats were attacked then.

“The big three votes were stimulus, cap-and-trade and then Obamacare," the operative said. “If you were to look at the early part of that cycle, a significant amount of them were on the stimulus.”

The 2010 election was largely fueled by energy from the tea party movement and Republicans tied vulnerable Democrats to their leadership in Congress including then-House Speaker Nancy Pelosi.

Democrats are hoping to similarly tie House Republicans to President Donald Trump and current Speaker Paul D. Ryan.

But the GOP operative said it might be harder to tie Republicans to Trump.

“Trump by his rhetoric is not a typical Republican,” he said. “The voter understands there is a difference.”

Jeb Fain, a communications adviser at the House Majority PAC, which works to elect Democrats to the House, said that while Ryan might have given some Republican members a pass to vote against the health care legislation, voters won’t.

“Records and votes matter,” said Fain, who worked for former New York Rep. Michael Arcuri — one of the Democrats who voted against the 2010 health care bill and still lost.

“Many of these members have voted multiple times to repeal to undermine the Affordable Care Act,” he said.

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