“At this point, Bill Cassidy owes Donald Trump nothing,” said Jason Roe, a veteran Republican strategist who worked for the presidential campaigns of Mitt Romney and Marco Rubio. “There’s no reward for standing by the president on a controversial vote.”

Cassidy, recently passed over by Trump for Rep. Julia Letlow (R-LA) in a contested primary, is far from the only committee member to express concerns during Means’ recent intense confirmation hearing. So too did centrist Sens. Susan Collins (R-ME) and Lisa Murkowski (R-AK), and dissension from any one Republican on the panel could spell doom for the nominee.

Unique to Cassidy, he holds the power to withhold a vote altogether, should it be determined that Means lacks the GOP support to advance to the full Senate. As chairman of the Health, Education, Labor, and Pensions Committee, the second-term senator was crucial to Kennedy’s confirmation but has since repeatedly criticized the Cabinet member’s vaccine policy changes, as have Collins and Murkowski.

“I’m not sure I know what you’re advocating for, which of course gives pause,” Cassidy, a liver specialist and gastroenterologist, said at one point during Means’s hearing as she danced around the subject of promoting child vaccinations.

“I want to back up and broadly just reassure you that this is not an issue that I intend to complicate or bring an agenda on vaccines,” Means said, at another point adding, “vaccine advocacy or any anti-vaccine rhetoric has never been a part of my message.”

Means is an ally of Kennedy and a doctor-turned-wellness-influencer with a popular following in the “Make America Healthy Again” movement. She’s facing bipartisan skepticism over not ruling out a link to vaccines and autism, sidestepping questions on using her would-be power to encourage vaccines against measles, hepatitis B, and the flu, and lacking an active medical license. Means also dodged whether access to abortion drugs should be available without an in-person office visit, but said “oral contraception should be widely accessible.”

Cassidy did not provide a comment for this story on his position on Means.

Seeking to alleviate concerns while walking a political tightrope not to contradict Kennedy or the administration’s controversial alterations to longstanding health and vaccine recommendations, Means repeatedly affirmed that “vaccines save lives.”

Trump’s endorsement of Letlow hasn’t stopped Cassidy from campaigning as though he has the president’s backing, whom he voted to convict of impeachment after the 2021 U.S. Capitol attack.

Cassidy said in a statement after Trump’s recent State of the Union address that he’s “worked with President Trump to deliver real results.” A separate campaign release, headlined “Trump Cracks Down On Liberal Letlow’s Insider Trading,” misleadingly suggested Trump was singling out Letlow’s stock trading disclosure violations by endorsing legislation during his speech to ban lawmakers and certain family members from buying stocks.

For Cassidy’s part, Collins and Murkowski are undecided on advancing Means’ nomination, a vote for which has not been scheduled. Given the committee’s split, a unanimous Democratic opposition would mean any Republican could torpedo Means.

TAKEAWAYS FROM THE INTENSE HEARING WITH TRUMP SURGEON GENERAL NOMINEE CASEY MEANS

The fate of her nomination will be played out by the time Cassidy’s political future is determined by Louisiana primary voters on May 16.

“I think Trump endorsing against him liberates him from reelection politics, and at this point, he’s free to do whatever he likes,” said Roe, the GOP strategist. “It’s much easier to stick to your principles when you’re liberated from the political calculation.”