Republicans are working against an angry public, internal divisions, and a host of distractions.
Over the past few days, the Trump administration delivered a major blow to transgender rights, set back prison reforms, and revealed disturbing details on the practical implications of its immigration-enforcement measures. But for all this tumult, this week was (again) relatively quiet when it came to major news or developments on key campaign promises. Both Donald Trump and Republican House Speaker Paul Ryan have indicated this may soon change. Trump and VP Mike Pence have recently been promising that a full Affordable Care Act (ACA) replacement plan, arguably Republicans' biggest priority, is on its way, while Ryan said last week Congress would deliver a plan after its recess this week and should get it passed by late March.
This outward resolve may soothe a base increasingly frustrated by the slow pace of real action in the Trump era. However, looking at where replacement plans are today, these promises may just be bluster, destined to disappoint even Trump and the GOP's base.
Both elected Republicans and right-wing think tanks have floated several ACA alternatives since 2009. However, as a side-by-side comparison chart of recent major plans put out recently by the Kaiser Family Foundation shows, in all this time they've never developed a consensus plan. There are a few recurrent themes across proposals—creating high-risk pools that would partition chronically ill patients who need a lot of care from the market, allowing insurance sales across state lines, encouraging the growth of health savings accounts, and killing the mandate to buy insurance, to name a few. But a lack of unity on the specifics, especially more controversial elements like funding mechanisms or the fate of Medicaid expansion, explains why the GOP has failed to meet Trump's campaign promises on the speed of repeal and replacement, and blew through their self-imposed January 27 deadline for devising legislation as well.
On Friday, Politico received a leaked version of a two-week-old House Republican bill that ought to send chills down the spines of anyone who gets coverage through the ACA. In addition to ticking most of the aforementioned points of GOP consensus, like eliminating the mandate requiring people to get insurance, it would strike down the ACA's Medicaid expansion and replace income-based tax credits based on income with age-based credits. As Vox explains, broadly this is better for young healthy people who don't need much care and worse for older sick people as well as the poor. It would also defund Planned Parenthood, a threat Republicans have often made. And in a move economists will love but many Americans will find controversial, it would cap tax exemptions for employer-provided plans in order to pay for a lot of what it proposes.
Whether that bill represents the current state of a House Republican plan is unclear. House conservatives have in the past been uncomfortable with some of its elements. But the House itself is just one battleground—any replacement will have to pass the Senate as well, and that's a taller order.
"I have no idea what the Senate is doing," says Sabrina Corlette, a former House staffer who directs research projects at Georgetown University's Center on Health Insurance Reforms. However, she cautions, "It is not typical for the Senate to defer to the House and take whatever they come up with."
Some senators have proposed or backed plans that look quite different from the House's—most notably Kentucky Republican Rand Paul's predictably libertarian proposal. More important, many Republican senators may find it hard to swallow the House plan's Medicaid rollback. A whopping 20 Republican senators hail from states that opted for Medicaid expansion and are less disposed to jigger with the program's current status quo than their House counterparts. Alaska Republican senator Lisa Murkowski has strongly indicated she might oppose any swipes at Medicaid, and some expect moderate Maine Republican Susan Collins to join her, which would almost be enough to guarantee the House plan's failure on its own.
Combine these concrete intra-party wedge issues with broader concerns—caught on audio at a Republican retreat in late January—about the political risks involved with replacement, and you've got a pretty good recipe for continued timidity, aborted grand plans, and stalls.
"We don't have details, and the GOP has been slow to release any," says the University of Massachusetts, Amherst, healthcare economist Gerald Friedman, who has worked on and supported single-payer system proposals, "because every plan they have will hurt someone, and there are real differences of opinion within the GOP."
In theory, the White House could help Republicans unify around a plan, as Obama did for the Democrats when they passed the ACA. However, while Health and Human Services Secretary Tom Price has ostensibly been working with Congress—and was expected, in the run-up to his 10 February confirmation, to have significant influence on final legislation—it's unclear what exactly he could be working toward, or how effectively.
So, despite talk of a coming grand plan, Corlette says it's impossible to even say for sure what will be in a final bill. There are still too many opaque processes and moving parts.
Corlette adds that it's also unclear how Republicans will try to implement it. Their current strategy is to use the budget reconciliation process to pass repeal and ideally some kind of reform with a simple majority vote. However, Corlette notes, "the provisions in reconciliation have to directly affect federal revenue or spending," which may be interpreted to preclude measures like allowing the sale of insurance across state lines. This may force Republicans to push elements of their plan into piecemeal ancillary legislation, which could in turn face a Democratic filibuster in the Senate, leaving them dead in the water.
It is entirely possible for Trump, Ryan, and company to deliver a full ACA plan next week as promised, and it may resemble Friday's leaked draft. But the notion that it will be passed in March is borderline farcical. In fact, there's some acknowledgement within the GOP (even in the recent past from Ryan and Trump) that we may never see any sort of repeal—the most recent and notable recognition coming via former Republican House Speaker John Boehner's Thursday remarks that the notion of repeal was laughable. There is some acceptance that the ACA framework could be kept in place, but "repaired"—a necessary move, given the flaws in the existing system.
Unfortunately, for the GOP, any delay on its floated timetables could cause serious troubles. As I noted last week, Congress will soon be forced to turn to other issues, like the federal budget, which could take away ACA momentum and reopen further internal GOP disputes. Corlette notes that insurers also have to make their plans as to whether to stay in healthcare markets and how to price their plans soon—the recent exit of Humana and scale-down of Aetna from participation in ACA exchanges shows that the uncertainty of the current political climate has many providers spooked. Strong language and executive actions from the White House could calm insurers, thus alleviating some time pressures on a replacement plan. But that sort of action seems unlikely given Trump officials' actions to date and the spate of policy issues and scandals they are having to deal with on a day-to-day basis. The more time that goes by without a bill passing, the more pressure and protests Republicans will face from constituents afraid of losing their insurance. That could make plenty of congresspeople skittish.
"If they don't do it quickly, then they will be in trouble," says Friedman. "Their base wants ACA repeal, but the longer they wait, the more opposition will develop."
All of which is to say that there's a real fire under Trump and the GOP's collective ass right now to find true consensus legislation and push it forward. There's just no real sign they're making the progress they need to on untangling knotty issues—and it's not clear how long they can go before people start calling this a failure.
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