Donald Trump and other GOP leaders face a nearly impossible task: asking conservatives and moderates to vote for the same thing.
Ever since House Republican leaders unveiled the 123-page American Health Care Act—on Monday, already so long ago—the replacement to the Affordable Care Act has been combed through by wonks from both sides of the aisle, who have mostly concluded it sucks. Democrats don't want to tear down the ACA, of course, since they expended an enormous amount of effort crafting and passing it in Barack Obama's first term, but it's Republicans who may doom the bill, even though President Donald Trump and House Speaker Paul Ryan are both pushing hard for it.
Republican critiques of the AHCA fall broadly into two camps. Hardcore conservatives, both in Congress and in advocacy groups, believe the plan maintains too much of the ACA's framework; some want a "clean" repeal, which would abolish the ACA full stop so they could start reform effort from scratch. Then there are moderate Republicans (especially those vulnerable to Democratic challengers) who will oppose any plan that might significantly reduce healthcare coverage nationwide, as this plan seems likely to do. Senators from states that benefited from the ACA's Medicaid expansion especially oppose the rollback of that expansion.
Both these groups are minorities within the Republican Party, and different representatives and senators have different incentives and views, of course. But given how narrow the margins for victory are—the plan can afford to lose 21 House and just two Senate Republican votes if Democrats unite against it—these critical coalitions matter. And with the caveat that it's early in the process, it's difficult to see how these groups will get to a place where they both feel good about the bill.
Party leaders, including Trump, are working to push the ACHA through over the objections of those two camps, even though the bill's impact has yet to be assessed by the Congressional Budget Office, a nonpartisan number-crunching agency. Congressional leadership especially has reportedly pushed the plan as a binary decision: Either you support it, or you implicitly support the ACA status quo. ACHA proponents have also tried to downplay criticism as ideological bluster that won't matter in the end or the result of misunderstandings about how it fits into a larger Republican healthcare agenda. Amid a heated public debate, the AHCA did manage to clear its first legislative hurdle late Wednesday night, passing markups in two House committees largely unchanged, which may seem like a victory for this party unity push.
The rest of the process isn't likely to go so smoothly, experts told me.
"I think there are a lot of Republicans who actually believe that if you get government out of the way, healthcare will be more abundant," said Mike Cannon of the Cato Institute, a libertarian think tank. "It will be more affordable, the quality will be better, and we will have less people on Medicaid." He added that from the perspective of this growing ideological wing, passing the AHCA would be worse than doing nothing as they believe the plan as it stands will be a massive failure due to its similarities to the ACA. "If they pass this bill," he said of the conservative attitude, "then Republicans are volunteering to take a bullet for Democrats and any hope of repealing [the ACA] is gone."
Trump and his team have signaled their willingness to negotiate elements of the plan to accommodate staunch critics' positions. And some detractors have reportedly come out of talks with Trump heartened, believing they can pull the bill towards the conservative side. (Conservative critics are the key force in the House and hence have received more attention at the outset than moderates.) Promising changes that can be made may not be enough to assuage some conservatives, though. According to Cannon, the most ideologically strident Republicans will insist on gutting everything that even resembles the ACA's key provisions from a final plan.
This faction may not be amenable to compromise because, as Gail Wilensky, a health economist with ample experience navigating government debates, put it, "some of the people who are, at the moment, yelling the loudest are the least practical among the politicians."
Any negotiation over the AHCD will be complicated. For one thing, different conservatives want different things. For another, concessions made to conservatives to pass the plan through the House may damn it in the Senate, where moderate concerns (especially about preserving the Medicaid expansion) are more salient to its success. "In fact," said Wilensky, "I'm not sure the bill they're considering [in the House] now could get through the Senate" because it is too harsh on Medicaid for some moderates. "Anything that moves it to the right [politically] would just compound that concern."
The seeming irreconcilability between the concessions conservatives in the House and moderates in the Senate would like to see in the AHCA may be why the Republican leadership apparently believes the plan as drafted is the best shot they've got at replacing the ACA. "Ryan's plan is an effort to steer between the two groups," explained University of Minnesota healthcare policy expert Lawrence Jacobs.
It's worth noting that the ACA itself weathered internal Democratic debates in 2009, with many on the left arguing Obama should advance a single-payer system and many moderates worried that the compromise legislation that emerged (which was based on conservative ideas) was still too radical—at least for voters who, they worried, would kick them out of this. (In fact, angry voters did unseat a lot of Democrats in the 2010 midterms.)
But this isn't an exact redux of 2009. Though Republicans complained about the ACA passing too quickly through Congress, they are also trying to rush the AHCA through even faster—possibly because they realize protracted exposure to internal debate and negotiation could doom the fragile middle path document. Also, the Republicans behind the AHCA drafted it largely in secret, even from members of their own party. Both moves may be strategic, but they also risk being more divisive.
That speed obviously hasn't shaken off criticism against the AHCA. Nor have proponents' best efforts eliminated the threat that internal discontent poses; as of publication, there were still more than enough Republicans in both chambers potentially leaning against the plan to stop it dead in its tracks. Wilensky cautioned that it's still very early on in the vote-wrangling process, no matter how accelerated it may be. "We'll see whether [leadership] can strong-arm, coerce, buy off—whatever else it is they do behind closed doors—to get support," she said. Those backroom machinations can, and often do, make or break deals like this , and the real calculus behind key votes is often not visible to the public. But going just on what we can see of the debate and dissent, things do not look good for the AHCA.
Follow Mark Hay on Twitter.