Update: Just before the House was due to vote on it, the American Health Care Act was pulled by Republican leadership, according to the Washington Posts's Robert Costa, who was on the phone with Donald Trump. Presumably, it was pulled because it didn't have the votes to pass.
As I write this on Friday afternoon, no one knows what the fuck is happening with the Republican healthcare plan. Top GOP leaders, including House Speaker Paul Ryan and President Donald Trump, have been trying to rush through a bill called the American Health Care Act (AHCA), a diluted version of Barack Obama's Affordable Care Act (ACA). But since the AHCA is opposed by all Democrats and a fairly large number of Republicans (especially conservatives), the vote on the bill in the House has been scheduled, rescheduled, and rescheduled again. The bill has also been revised multiple times in order to appease conservatives. Thursday night, just after the latest vote delay, Trump issued an ultimatum: The vote should happen Friday (on a bill that was just finalized this morning). If the AHCA failed to pass, Trump would supposedly leave the ACA in place. Right now, it's unclear if Ryan has enough votes to get it through the House, but White House press secretary Sean Spicer said a vote would be scheduled for 3:30 PM EST anyway—though who knows if it will be rescheduled again.
If it does pass the House, the AHCA almost certainly won't be able to pass the Senate. If it doesn't, it will be a striking failure on the part of Trump, who's sold himself as a master dealmaker, and Ryan, who like most Republicans has wanted to repeal the ACA for years.
So, how did we get here?
The nation is ultimately in this mess because the AHCA is a supremely shitty bill. While it seemingly sought to strike a conciliatory middle path between competing interests within the GOP, almost every possible faction has panned the AHCA, with some Republicans going so far as to say it could be worse than the hated ACA. The more people learn about it, the more they seem to hate it; it had just 17 percent of the country's support in a recent poll.
"The only thing one can conclude is that Trump trusted Ryan to deliver the goods and Trump has no understanding of what is in the bill," said University of California–Berkeley healthcare expert Helen Halpin. "It is actually really difficult to write a bill that is this universally hated by everyone—liberals, conservatives, and independents."
Any effort to repeal the ACA was going to face stiff opposition from Democrats. But the AHCA is actually doomed because of congressmen to Ryan's right. The Freedom Caucus, a group of three dozen hardline conservative House Republicans who have a history of opposing not just Democrats at every turn but also GOP leadership when they see that leadership as weak, made it painfully clear they would oppose the bill—and had the votes to kill it. (The AHCA can't lose more than 21 votes in the House.)
Trump personally took point on negotiations with the Freedom Caucus. On Monday, the bill's crafters added amendments speeding the repeal of ACA-related taxes, opening up the possibility of work requirements on Medicaid, and rejiggering funding for older Americans, mostly changes demanded by conservative interests. (The nonpartisan Congressional Budget Office reviewed these tweaks on Thursday and found they would not result in more people having insurance, but would save the government less money than the original.)
These initial concessions failed to appease conservatives, who pushed first to see the AHCA ax the ACA's ten essential healthcare benefits (medical services every plan on the market must cover) in the name of creating a deregulated market. When Trump expressed his willingness to consider such an amendment, conservatives made it clear that would not guarantee their full support either. They pushed further to eliminate all the ACA's insurer regulations, including popular provisions banning companies from discriminating against people with preexisting medical conditions and allowing children to stay on their parents' plans until age 26.
Each of these concessions to conservatives alienated moderate Republicans, even some typically firm allies of the leadership, who were not calmed by Trump or his proxies. Many were reportedly scandalized by how much had been ceded without securing definite support from the Freedom Caucus. Others grumbled about the opacity of the revisions being made to the bill, or worried that it would result in insurance becoming too expensive for their constituents. It seemed like Ryan might pursue an open-ended delay of the vote and possibly start a longer negotiation process.
Instead, Trump made his ultimatum, indicating that he didn't want to wait. He started Friday by calling out the Freedom Caucus on Twitter, and was later demanding a vote, even as Ryan headed to the White House to tell the president the support wasn't there.
Critics see the ultimatum as an act of rage from a notoriously impetuous politician who reportedly has little interest in the details of and is increasingly frustrated by healthcare policy. As Halpin sees things, Trump is "ready to move to another policy arena—tax reform—where he has a better chance of a win. He wants to drop this like a hot potato… 'Failing' is his best option, because the impacts of this bill on the lives and well-being of millions of Americans would be devastating. The fact that he isn't even staying in Washington for the vote suggests he has concluded it is a loser. He will blame Ryan and the Republicans and take no responsibility for the disaster."
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By Friday morning, leadership has caved to Freedom Caucus demands on dismantling the ACA's essential health benefits—making this a harder vote for any Republican who worries about being called heartless by a Democratic opponent in 2018. As a sign of this bill's unpopularity, a late-night vote allowing the bill to be heard right out of committee saw four Republicans saying no—a rare note of dissent in what's usually a perfunctory process.
Mike Cannon of the libertarian Cato Institute, who has harshly criticized the ACA, says many conservatives in Congress truly believe voting for this bill is worse than voting for nothing at all. These individuals are willing, he told me, to push ahead on a full repeal bill with or without Trump's support, and may actually see the collapse of the AHCA as a benefit, giving them time to carefully build their case with moderates.
"I don't think that [Trump's] bad-cop routine is going to have the effect of making them all think this is their only opportunity," said Cannon, who also doesn't buy the idea the president will walk away from healthcare. Trump, Cannon said, likely realizes he can't do so because he needs the AHCA's cost savings to justify other initiatives like tax cuts.
Few people think the bill will pass on Friday—but not many are willing to make predictions, especially since the president is involved. (Remember November?) Trump has characteristically flipped the political script by charging headlong into a vote that has uncertain outcome. That might be a calculated move to keep his opposition off-balance and force House Republicans to take a tough vote. Or it might just be a mistake.
That uncertainty created a fracas of rage and recrimination among the GOP that is one part House of Cards and ten parts VEEP. But this isn't TV; things tend to happen slowly in Congress. Even if the House passes the AHCA, it's only the start of a long slog that will probably be even more brutal and tense in the Senate, where there'll be parliamentary procedure subplots as well as substantive negotiations, likely more focused on moderate Republican dissent and constrained by a smaller margin of Republican control in that chamber. If the bill is altered, it would swing back around to the House for yet another round of deliberations. This level of uncertainty is draining at the very least and could be damaging to Republican Party unity—not to mention the stability of the American healthcare market.
"No one has ever seen anything like this," concluded Halpin. "It is chaos. It is frightening."
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