When we last left the American Health Care Act, the GOP’s plan to ‘repeal and replace’ the Affordable Care Act, Republicans were struggling to find the votes necessary to pass the bill in the Republican-controlled House of Representatives thanks to resistance from the House Freedom Caucus, who feel the bill doesn’t go far enough in repealing various popular measures in the PPACA and moderate Republicans who believe it goes too far and that the proposals from the Freedom Caucus are a ‘poison pill.’ By the end of the afternoon, Republican leadership had decided to pull the bill from the House floor and reschedule it for today, and the Trump Administration was issuing an ultimatum, pass the bill or we walk away from health care reform altogether:
WASHINGTON — President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a Friday vote on a bill that appeared to lack a majority to pass.
The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump — who has boasted of his deal-making prowess — fell short of selling members of his own party on the health plan.
House Speaker Paul D. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters’ questions about whether he expected the measure to pass.
Although the House Republicans’ closed-door meeting became a cheerleading session for the bill, their leaders braced for a showdown on the floor, knowing they were likely to be at least a handful of votes short of a majority for the health insurance bill and would need to muscle their colleagues to the last to prevail.
Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others, meanwhile, were grappling with worries of their states’ governors and fretted that the loss of benefits would be too much for their constituents to bear.
Mr. Ryan had earlier postponed the initial House vote that was scheduled for Thursday to coincide with the seventh anniversary of the Affordable Care Act’s signing. Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.
At a White House meeting with members of the hard-line Freedom Caucus earlier on Thursday, Mr. Trump had agreed to the conservatives’ demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, part of the reason that Thursday’s vote was placed on hold.
As House leaders struggled to negotiate with holdouts in the hopes of rescheduling the vote, Mr. Trump sent senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama’s signature domestic achievement in place.
“We have a great bill, and I think we have a good chance, but it’s only politics,” Mr. Trump said earlier Thursday, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan — which was years in the making — to repeal and replace the health law.
Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump’s chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
Mr. Trump, who has touted his negotiating skills and invited the label “the closer” as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
“Guys, we’ve got one shot here,” he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. “This is it — we’re voting now.”
“The choice is yes or no,” Representative Joe Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. “I’m not going to vote no to keep Obamacare. That’d be a stupid damn vote.”
Others were unconvinced.
Having secured Mr. Trump’s acquiescence to eliminate the requirement that insurers offer “essential health benefits,” members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents’ health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
“We’re committed to stay here until we get it done,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. “So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.”
He said 30 to 40 Republicans planned to vote “no”; House leaders can afford to lose only 22 in order to pass the bill.
But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill’s Medicaid cuts and slashed insurance benefits. Moderate Republicans in that group went to the White House on Thursday but emerged unmoved in their opposition.
“There’s a little bit of a balancing act,” conceded Sean Spicer, the White House press secretary.
Representative Leonard Lance, Republican of New Jersey, said he still opposed the bill because he did not believe it would give people “complete and affordable access” to health insurance.
The news about the rescheduled vote came less than an hour after a revised report from the Congression Budget Office that re-scored the bill after taking into account the changes that have been made since the first CBO report. If anything, the changes have made the AHCA seem even worse than it originally appeared to be in the first CBO report. For example, the report found that the revised bill would result in 24 million fewer Americans having health insurance coverage in ten years than under existing law. Additionally, the changes would cut the deficit ‘savings’ from the bill from $337 billion to $150 billion over that same period. Not accounted for in the report were other changes and proposed changes to the PPACA that are reportedly still being considered this morning, including stripping from the law the provisions requirement that all insurance policies cover a defined list of medical conditions, including guaranteed coverage for people with pre-existing conditions and the provisions that allow children to stay on their parents policies up to the age of 26. Eliminating both of these provisions would likely increase the number of uninsured Americans even further than the current CBO estimates. Of course, under the current plan in the House if these provisions are stripped from the bill there will not be sufficient time for the bill to be scored yet again by CBO, and there won’t even be time for members of Congress or the public to see the bill that Congress will be voting on before it gets passed.
These developments also come at the same time that polling indicates that the Republican health care plan is not exactly popular with members of the public. A new poll from Quinnipiac University, for example, finds that just 17% of Americans support the AHCA while some 56% oppose it. Other polling shows that support for the PPACA has actually grown in the weeks since the AHCA was introduced. Additionally, Members of Congress are reporting that phone calls to the Washington and District offices are running overwhelmingly against the bill, which is only likely to reinforce those Republicans who are on record as being against the bill to remain opposed notwithstanding the pressure they are no doubt feeling from House leadership and the White House. Indeed, as things stand this morning it remains entirely unclear whether House Republicans have the votes to pass the bill today any more than they did yesterday, and that’s why it’s entirely unclear what will happen today.
As things stand, it seems likely that the House will only hold a vote if the leadership is reasonably sure that they have the votes to get the bill pass if only because the news going into the weekend that the bill was defeated on the floor would be seen as a massive loss for the President and the leadership that they can’t really afford right now. Notwithstanding the President’s ultimatum, they could also decide to push the vote to the weekend or early next week to try to get the votes they need but given the fact that we’ve gotten this close to a vote and they still can’t say for sure if they have the votes is a strong argument for the idea that either the bill passes today or it isn’t going to pass in its present form at all.
Of course, even if the AHCA passes the House, it still has the Senate to contend with. First, there will be the issue of whether or not Republicans will be successful in getting around the sixty-vote threshold normally required for legislation by invoking the reconciliation process, an issue that remains unclear given current Senate rules. If they aren’t able to do this, then the bill will essentially be dead in the water since there’s no way the GOP will get sufficient Democratic votes to invoke cloture on the bill as it is. Even if they are able to invoke reconciliation, though, the fate of the bill remains unclear because it doesn’t appear that there are at least 50 Republican votes to pass the bill in its present form. Conservative Senators such as Rand Paul, Ted Cruz, and Mike Lee have already said that they oppose the bill and their opposition alone would be enough to prevent the bill from passing. In addition to the conservatives, though, there have also been signals from some moderate Republicans that they have problems with the AHCA, problems that are only likely to increase if the final bill out of the House is changed in the way that the House Freedom Caucus wants. What all of this means is that the Senate is likely to make its own changes to the bill, many of which are likely to be anathema to the House, and the whole matter will either head to a conference committee or collapse under its own weight. Given that, one wonders why any House member currently opposed to the bill would change their mind and put their necks on the line for a bill that isn’t going to pass anyway.
Update: The AHCA was pulled from the House floor before a final vote could be held. Details in my afternoon update.
