Like the penultimate episode of a television reality show, the debate over the Republican plan to repeal and replace the Affordable Care Act on Thursday was marked by conflict, confusion, and finally, a grand ultimatum from Donald Trump. The president demanded a final vote on the measure in the House of Representatives and vowed to walk away from the GOP’s American Health Care Act if the vote fails, leaving Obamacare in place.
Trump’s move set up Friday as the final episode in the drama that has consumed much of the first weeks of his presidency. But unlike”The Apprentice,” the television program that defined his public persona throughout the decade before he entered politics, it’s not Trump who will have the final say over who comes away a winner today.
As of early Friday morning, the House Rules Committee had convened in a necessary step before the bill can be brought to the floor of the House for debate and a vote. The meeting was contentious, with Democrats plainly unhappy about the shape of the legislation. Even House Ways and Means Committee Chair Kevin Brady of Texas admitted that it was unusual for the House to move to vote on a bill without an accounting of its costs and impacts from the Congressional Budget Office, which late amendments had made impossible.
The AHCA, which would repeal the Affordable Care Act, has zero Democratic support in the House of Representatives, meaning that Republicans need to find all the votes needed to pass it on their own side of the aisle. But as hard-core conservatives demanded more and more changes in exchange for their votes, Trump and House Republican leadership found themselves losing support from the party’s less-doctrinaire members, who believed the bill had become too draconian in cutting funding and services to the most vulnerable.
Trump, evidently frustrated with the process, sent his budget director, former House member Mick Mulvaney, to Capitol Hill on Thursday afternoon with a blunt message: The president was finished negotiating, and demanded that the House vote on Friday. If the bill fails, he added, Trump will abandon the effort to repeal the Affordable Care Act and move on to his other legislative priorities, including tax reform and an infrastructure program.
Whether moving on will be as easy as Trump seems to think is an open question. If this bill goes down, he will have suffered a major blow to his credibility as a leader -- particularly given his self-proclaimed mastery of the art of dealmaking.
But the decision to force his adversaries’ hand had the support of House Speaker Paul Ryan, who arguably has even more of his reputation riding on the AHCA. While the White House has no actual authority to compel a vote in the House of Representatives, Ryan was fully supportive of the gambit.
“For seven and a half years, we have been promising the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” he said after a meeting of House Republicans. “And tomorrow we’re proceeding.”
Indeed, the vote on the bill has been characterized by Trump and his surrogates as a sort of loyalty test. With virtually all Republicans in Congress having run on the promise to eliminate the ACA, they warn, failure to support AHCA will be seen as a betrayal that could cost them their seats in the next election. Not far below the surface is the suggestion that it is also a test of their loyalty to the first Republican president that many of them have ever served with.
The bill the House will proceed with underwent several last-minute changes meant to make it more attractive to wavering members.
The conservative members of the House Freedom Caucus, who represent the core of the opposition to the bill, had demanded, among other things, that the bill eliminate a suite of “essential health benefits” that all insurance plans sold on the ACA health insurance exchanges were required to include. Among them are mental health and addiction services, outpatient treatments, hospital stays, maternity and newborn care, and more.
In the end, they were offered a half-measure. A series of amendments to the bill pushed the responsibility for determining what benefits are “essential” was pushed down to the states, a change that would take effect in 2018.
As an offset, the changes dedicated more money to the Patient and State Stability Fund, a program meant to help ease the transition to the new system by providing financial assistance to individuals, incentives to insurers, and other measures. The amendments add $15 billion to the PSSF, all dedicated to maternity and newborn care and addiction and mental health services -- two of the essential health benefits that lawmakers worry would be most likely to be eliminated.
The proposal would pay for the change by retaining through 2023 a 0.9 percent additional Medicare tax on people earning more than $200,000 per year, or married couples earning more than $250,000. However, a key demand of the Freedom Caucus in early negotiations had been an accelerated repeal of Obamacare’s taxes.
As of early Friday, it remained unclear whether or not the changes would be sufficient to bring along enough members of the Freedom Caucus or if the prospect of allowing states to slash essential health benefit requirements would drive Republicans at the other end of the conference’s ideological spectrum away from the bill.
The legislation wasn’t made any more attractive by a report from the Congressional Budget Office that came out late Thursday afternoon. The CBO report only dealt with the proposal as it had existed earlier in the week, and did not take the new amendments into account. However, it found that earlier amendments raised the cost of the bill without having any impact on the number of Americans with health insurance. The AHCA, CBO reported, would still result in 24 million fewer Americans with health coverage after a decade.
The fate of the bill in the House remained very much in question Friday morning, but even if Trump and Ryan are able to successfully call the bluff of the Freedom Caucus, the AHCA is facing an even tougher battle in the Senate. In the upper chamber, Republicans can only afford to lose a maximum of three votes -- assuming that Vice President Pence would break a tie -- but more than a dozen GOP senators have expressed serious skepticism about the legislation.