The Trumpcare Bill Is More Vulnerable From the Left than the Right

Paul Ryan and the rest of Republican leadership are now trying to push their health care bill — called the American Health Care Act officially, but Ryancare or Trumpcare by trolling Democrats — through Congress. Since Republicans have a majority in the House and the Senate and are using a legislative strategy that only requires 50 votes in the Senate, they can pass the bill with only Republican votes. If the bill is to be derailed, then, it will be by Republican defections.

In the few days since the bill became public, the Republican opposition attracting the most attention has been from House Freedom Caucus members who think Trumpcare does not roll back Obamacare enough — that is, they think that the bill is too liberal. They don’t like that the Medicaid expansion isn’t rolled back until 2020, they don’t like the tax credits offered to exchange participants, and they don’t like that the individual mandate and other regulations persist. Some of these opposing Representatives have claimed that the bill is too liberal to get through the House in anything like its current form.

I am skeptical. For one thing, although a few HFC members like Mark Meadows, Justin Amash, and Jim Jordan, have been outspoken in opposition to the bill, some others like David Schweikert and Randy Weber seem in favor. So far, there haven’t been enough members publicly opposing the bill to sink it. Republicans have a pretty big House majority — there are 237 Republicans in the House right now, and they only need 216 votes to pass a bill. So even if half the Freedom Caucus votes against, they can still pass the bill. Lastly, although many HFC members would prefer a clean repeal of Obamacare without any replacement to the AHCA, they pretty clearly prefer passing the AHCA to passing nothing at all. And they may eventually realize that the AHCA is pretty close to a clean repeal, especially if Ryan’s mythical Phase 2 and Phase 3 materialize. In the end, I think that for all the noise these conservatives in the House are making now to try and force changes to the bill, enough will vote in favor that the bill passes the House. Ryan seems to be making the same bet.

The AHCA’s more difficult problem is that there are a number of Republican Senators who think the current bill is too conservative. This includes at least the foursome of Rob Portman, Shelly Moore Capito, Cory Gardner, and Lisa Murkowski who sent a letter to Mitch McConnell asking that the Medicaid expansion be preserved in some form, and Susan Collins who has “concerns” about the AHCA’s impact on the Medicaid population in her state and who opposes (along with Murkowski) the defunding of Planned Parenthood. That’s five Senators. (Update: there may be one more.) With 52 Republicans in the Senate, the bill can only afford to lose three supporters.

This isn’t the end of the bill’s problems in the Senate. There are also three Senators — Rand Paul, Mike Lee, and Ted Cruz — who have expressed opposition to the bill from the right, with many of the same grievances submitted by the House Freedom Caucus. But I think this opposition is less steadfast, especially in the case of Rand Paul. Rand Paul’s home state of Kentucky has benefitted more from the Medicaid expansion than perhaps any other state. Paul’s libertarian politics do not allow him to advocate for the Medicaid expansion explicitly, but it may be that his principled conservative opposition to the bill is really a smokescreen in order to preserve benefits for his constituents. Tom Cotton from Arkansas might be in the same situation.

So while the current bill stands a pretty decent chance of making it through the House, it seems dead-on-arrival in the Senate. The five Senators opposing the bill from the Left are making a more credible threat to vote against the bill, because although they all, being Republicans, say they oppose Obamacare, they may actually prefer the status quo with Obamacare to the AHCA.

Where does this leave the bill? Some have argued that GOP leaders are hoping to run into Senate opposition, shrug their shoulders, and try to go back to their voters and say, “oh well, we tried.” I doubt it. First, the GOP has been running on repealing Obamacare for seven years now. There will be political hell to pay if they don’t do something. Ryan (and to a lesser extent Trump) have already put significant political capital behind this bill. Its failure would be an embarrassment. But even more importantly, as Catherine Rampell explains in the Washington Post, Ryan has to pass the AHCA before he can get to his real goal of corporate tax reform. Giving up on the AHCA means giving on tax reform too, and that is not something Ryan will give up on easily. So how will he try to pass the AHCA, or something like it?

If the Senate is the bottleneck, the bill would need to change in such a way that the Senate might pass it, but not so much that it couldn’t still get 216 votes in the House. If I were Paul Ryan (horrifying to contemplate, but this is the exercise I have assigned myself), this is what I would try:

  • Keep the bill’s increased state flexibility for Medicaid funds, but increase funding back to Obamacare levels (as calculated by the Cassidy-Collins bill)
  • Don’t defund Planned Parenthood
  • Kill the exchanges entirely. Set all the tax credits in the current bill to zero. Eliminate the continuous coverage rule in the current bill. Have an understanding with the administration that the essential health benefits rules will not be enforced, nor guaranteed issue and community rating. This will surely create legal challenges, but you’ll deal with that later. For now this is just a thing to say to conservatives to get the bill passed.
  • Extending Medicaid funding costs more than killing the tax credits saves, and Senate rules require that a reconciliation bill not increase the deficit beyond the 10 years following the bill’s passage. So there would need to be either a new tax or more cuts somewhere to satisfy this requirement. The easiest thing to do would be to create a new tax (probably a payroll tax, since Republicans hate taxing the rich and payroll taxes fall most heavily on lower and middle-income brackets) that would begin starting in 2027. That would be far enough away to blunt political opposition to a new tax, and maybe the tax could be reversed in ten years once it arrives.

Extending the Medicaid expansion and preserving Planned Parenthood funding might be enough to appease the Senators opposing from the left. If there are stragglers, maybe they can be bought off with an updated version of the “Louisiana Purchase”.

The total destruction of the exchanges and the accompanying regulations would keep the conservatives in the House happy. Eliminating all the regulations through executive action would be unsatisfying because it could easily be reversed by a future Democratic president. But the only alternative would be to somehow overrule the Senate parliamentarian on what can be done in a reconciliation bill, and there probably wouldn’t be enough votes for that maneuver.

There’s no doubt that Trumpcare is going to a tough sell, whatever direction it moves in. But the firmest opposition the bill faces right now is from the left, and that flank will have to be appeased before a bill can get through.