“Let’s face it,” Sen. Orrin G. Hatch of Utah said. “The House bill isn’t going to pass over here.’’
So the Republican Party’s seven-year crusade to repeal the Affordable Care Act begins anew for the 58th time. That number, alas, is no exaggeration.
The first 55 times House Republicans voted to repeal Obamacare, they were thwarted by President Obama’s veto power. The 56th time came in March when the Republicans controlled all three branches of government for the first time. Having seven years to prepare replacement legislation, the GOP offered up the American Health Care Act (call it AHCA 1.0). The Republicans held no hearings, consulted with no interest groups, avoided all debate. The legislation was so unattractive it died before even coming to a vote.
The 57th time came last week when the House passed a revised version of the AHCA—call it AHCA 2.0—which was immediately dismissed by Republicans and Democrats alike in the Senate.
Now the 58th effort to repeal and replace Obamacare is getting underway. Led by Senate Majority Leader Mitch McConnell and his handpicked Gang of 13 (all of them white men), the Senate Republicans face the same political challenge as their House counterparts: how to deprive millions of Americans of health insurance without actually admitting that’s what they are doing.
The preferred solution of House Republicans in the wake of AHCA 2.0—to lie, dissemble and spin—was so implausible that even Senate Republicans wasted no time in repudiating the House bill, even if they could not say what they would replace it with.
“All they know is that the American Health Care Act is a toxic product, they didn’t think they’d have to deal with this anymore, and they’re determined to at least create the impression that they’re starting from scratch,” writes Jim Newell of Slate.
Here are six realities that the Senate Republicans now face in passing health care legislation.
1. Millions Harmed
The House voted on AHCA 2.0 before the non-partisan Congressional Budget Office could do an analysis of its cost and reveal how many people it would deprive of health insurance. The CBO’s initial estimate that 24 million more Americans would lose their health insurance within a decade spooked many lawmakers in the upper chamber.
“You can’t sugarcoat it,” Senator Bill Cassidy (R-Louisiana) told Fox News. “It’s an awful score.”
Given the stately decorum of the upper chamber of Congress, there will be plenty of time for CBO to score the Republican bill. No one knows how many people it will throw off the insurance rolls, but it is most likely an eight-digit number. Otherwise, Republicans won’t save enough money to fund their tax cuts.
2. Moderate Republican Worries
The Republicans how hold 52 seats in the Senate. They need 50 votes, plus the tie-breaking vote of Vice President Mike Pence, to pass a bill. But there are a half-dozen Senate Republicans who have already indicated AHCA 2.0 is a non-starter.
Two of them, Susan Collins of Maine, and Louisiana’s Cassidy, have introducted their own health care legislation, which would scale back spending on Obamacare, but not change the architecture of the health insurance system. It’s a reasonable compromise, which is why it has absolutely no chance. But Collins and Cassidy will have leverage in negotiating with McConnell and more conservative colleagues.
3. Popularity of the ‘Pre-Existing Conditions’ Ban
Obamacare eliminated insurance companies’ right to refuse coverage based on pre-existing conditions. The provision is so popular that the authors of ACHA 2.0 made sure they did not actually use the term in their bill, the better to buttress the lie that the bill will not deny coverage to people with pre-existing conditions.
Dean Heller (R-Nevada), the only GOP senator up for reelection in 2018 in a state Clinton won, was not fooled. He came out against the House bill hours after it passed, saying, “We need assurances that people with pre-existing conditions will be protected.”
Nor was Collins fooled.
“It’s true that under the House bill that a state that gets a waiver would still have to provide coverage to people with pre-existing conditions,” she told ABC News. “But that coverage might well be unaffordable. And if the coverage is unaffordable, that doesn’t do any good for a child who has juvenile diabetes and is going [to] have that her entire life.”
On the one hand, these swing-vote Republicans will be in a position to protect those with pre-existing conditions as the legislation is drafted.
On the other hand, Josh Marshall reminds us of an Iron Law of Washington politics: “Moderate Republicans Always Cave.”
4. Popularity of Medicaid Expansion
Despite President Trump’s campaign pledge not to touch Medicaid, the House bill proposes cutting $880 billion in Medicaid funding over the next decade, which is one reason so many senators declared the bill DOA.
In March, Republican senators Rob Portman, Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) wrote a letter to McConnell in March stating that they wouldn’t support the House’s treatment of Medicaid expansion.
“We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,” they wrote.
Republican governors in at least four states share those concerns. In a letter to House and Senate leaders, the governors of Ohio, Michigan, Arkansas and Nevada declared that AHCA 2.0 “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states.”
On the one hand, McConnell and the Gang of 13 may have to scale back the Medicaid cuts to gain the votes of the moderate bloc. On the other hand, see Marshall’s Iron Law, above.
5. Premiums Sure to Rise
Even with the $85 billion added by House leaders to help older people pay for their insurance premiums, Kaiser Health News reports that “many moderates feel the age-based tax credits in the bill replacing those in the Affordable Care Act are too small, particularly for people in their 50s and early 60s. “
The CBO estimated that under AHCA 1.0, the premiums for a 64-year-old with an income of $26,000 a year could rise from $1,700 currently to more than $14,000. AHCA 2.0 is likely just as bad if not worse, for low- and middle-income households.
“Older people buying their own insurance, especially those with lower incomes, are probably the hardest-hit group under this bill,” Larry Levitt, a senior vice president at the Kaiser Family Foundation, told the Wall Street Journal.
Any effort to prevent premiums from rising would require keeping, not repealing, the Obamacare subsidies. One possible solution: keep the Obamacare subsidies and rebrand them as Trumpcare. For those who believe in “alternative facts,” this might be plausible.
6. Sick People Pay for Tax Cuts
“The House’s plan offered a spectacular tax cut for the wealthy — those in the top one-tenth of one percent of incomes would get tax cuts averaging more than $200,000,” writes Paul Waldman in the Washington Post. How much the Senate health care legislation benefits America’s richest familes will be a key feature of the Senate debate.
Which points to the underlying reality. Obama’s Affordable Care Act was a reasonable compromise between the many stakeholders in the health care system: patients, doctors, hospitals, insurance companies, and taxpayers. Trump’s AHCA is an effort to tear down and rebuild the system without consulting any of the stakeholders, save high-income taxpayers, the only group of Americans sure to benefit if the Senate passes some version of health care “reform.”