Something extraordinary is on the cusp of taking place in Washington on Thursday.
An unpopular president and a House Republican leadership team with a seemingly weak grasp of its own members’ priorities is preparing to rush through legislation that would trade 24 million people’s health coverage for a huge tax cut on wealthy households and health care corporations.
This nearly friendless plan goes by the name of the American Health Care Act, a dull title that belies not only the havoc it could wreak on the health care system but the chaos it’s creating within the Republican Party, from the White House to Capitol Hill to the monied interests that fund the GOP’s agenda.
The Republican health care reform bill polls poorly, has sparked protests across the country, and would have disproportionately harmful effects on the older, poorer and rural voters often credited with President Donald Trump’s electoral victory while having disproportionately positive effects for well-off urbanites.
It doesn’t solve the Affordable Care Act’s problems, or fulfill Trump’s promises to offer universal coverage or his and other Republicans’ promises to reduce health care costs for consumers.
House Speaker Paul Ryan (R-Wis.) will ask his majority to vote for this bill despite all this, and without providing them with a Congressional Budget Office analysis of what effects the latest version of the bill would have on the number of Americans with health coverage or what that coverage would cost. The White House and GOP leaders were even making major changes to the bill that would undermine consumer protections late Wednesday night.
And Ryan intends to hold this vote with no idea what the outcome will be.
If it gets through the House, Senate Majority Leader Mitch McConnell (R-Ky.) says he’ll have it on the floor of the upper chamber next week, even though enough Republican senators have spoken out against the bill that it could fail to get a majority in the Senate.
The best reason any Republican can come up with for passing this bill is that they said they would. The pretense that the legislation will result in better health care all but fell by the wayside once the CBO concluded tens of millions would lose their health insurance.
As one person said Wednesday, “Simply put, this bill does not meet the standards of what was promised; it is not as good or better than what we currently have.” That person was 11-term Republican Rep. Frank LoBiondo (N.J.).
To understand how a bill with such little apparent political upside could actually be this close to becoming law, one must first understand the driving dynamics of the modern Republican Party. It is, fundamentally, a party that’s inoculated by congressional districts drawn in its favor, and that’s driven by process as much as policy.
There is a zeal to exact revenge on former President Barack Obama and the Democratic Party and to fulfill its promises to “repeal and replace Obamacare” that could overwhelm any other consideration. And there is also a belief that a legislative “win” ― even for a piece of legislation this universally disliked ― is as important as the policy outcome it produces.
“Right now the Republican base is holding solid, and most of these House members are from solid districts,” said former Rep. Tom Davis (R-Va.) “So if the base holds, the members will be fine. Most of them. But if they don’t do this, the Republican base gets pissed. They start to not have faith in their own members and that’s when you see these big problems.”
“The worst thing that can happen is it goes down,” Davis added. “That is a worse result for you because at that point your base collapses. I don’t think there is any way they can not pass something and the majority survives.”
This view is shared not just by former members but by current ones as well. The prevailing wisdom on Capitol Hill is that if health care reform doesn’t pass, the Republican Party’s entire agenda may be imperiled.
That’s one of the reasons why Trump has fully embraced the bill and why Ryan remains determined to force this bill to the floor Thursday ― the seventh anniversary of the Affordable Care Act’s enactment ― after forcing it through four committees in two weeks, in the face of strong opposition within his conference the entire time.
Doing a worse thing is not better than doing nothing at all. Be careful what you wish for.
Dave Carney, Republican operative
But beyond Trump’s White House, House GOP leaders and rank-and-file House members who will vote as they’re told, it’s not easy to find many people who actually want this legislation to become law.
Trump’s vaunted (at least in his own estimation) dealmaking prowess has had a limited effect on the members of his own party who oppose it to date. Blocs of conservatives and moderates have expressed dislike of the bill for different reasons. And though Republicans now control all the levers of the federal government, even repealing the hated Affordable Care Act might be beyond their grasp.
And that’s because of another dynamic of the modern Republican Party: In certain quarters, it pays to be antagonistic. The Republican Obamacare “replacement” is opposed by the Heritage Foundation, the Club for Growth, FreedomWorks and even the notoriously pro-Trump Breitbart News.
The House Freedom Caucus, a collection of hard-line, tea party conservatives, has opposed Ryan and Trump’s plan because it doesn’t take away health care from enough people fast enough.
And in a twist of irony, these conservative lawmakers who have been holding out stood as the greatest hope liberals have that the Affordable Care Act safety net will remain in place.
The White House and GOP leaders, however, may have won over enough of them by considering changes to the bill that would, among other things, allow insurers to go back to selling policies that don’t cover basic benefits. But this may further alienate moderates and could run afoul of Senate budget rules.
Part of the opposition from conservative lawmakers and groups has been based on the notion that the GOP health care bill is not pure enough. But some of it is tied to the concern that the end product would harm their own base of voters: the rural, the elderly and the working poor.
“The argument is we have to do something,” explained Dave Carney, a longtime GOP operative based in New Hampshire. “I’m saying, doing a worse thing is not better than doing nothing at all. Be careful what you wish for. Any bill that protects insurance companies and not individuals is a political loser.”
Both Carney and Davis suggested that, ultimately, the House would pass a bill with the hope that it ends up being changed or, perhaps, killed by the Senate.
Republicans in the upper chamber seem more attuned to the politics at play ― perhaps because they must run statewide.
The health care sector almost uniformly rejects this legislation. The health insurance industry is delicately balancing its support for short-term funding that would benefit them with its anxiety about longer-term cuts to Medicaid and health insurance subsidies that would harm them. Consumer groups like AARP and the March of Dimes are marshaling their forces against it.
Mainly, however, they recognize that especially in those states that used Affordable Care Act money to expand Medicaid, the Republican Party would shoulder all the blame for having millions of people lose coverage and access to care.
Still, should the bill die in the Senate after having passed through the House, the same conclusion will have been reached. Republicans made promises on health care they couldn’t keep, and it might finally be catching up to them. If the bill fails, their years of promises of repeal will have been exposed as empty. If this bill passes, their voters will find out what it does.
People, after all, tend to notice if their health insurance gets worse or more expensive. Just ask Barack Obama.
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