It is a practical, 3-part process, against which no Republican can afford to vote.
The tsunami of criticism that greeted last week’s introduction of the American Health Care Act (AHCA) was probably inevitable, considering the questionable character of some career politicians, the liberal inclination of the legacy media, and the hopelessly convoluted maze of mandates, taxes, and regulations that is Obamacare. Even honest observers got important details of AHCA wrong, while failing to comprehend its place in the overall GOP plan to rid the nation of the “Affordable Care Act.” Saturday morning, President Trump used his weekly address to clear up some of the confusion:
This plan is part of a three-pronged reform process. In concert with the plan in front of Congress, I have directed Dr. Tom Price, our Secretary of Health and Human Services, to use his authority to reduce regulations that are driving up costs of care. We are also working on reforms that lower the costs of care, like allowing Americans to purchase health insurance across state lines.
If Trump’s reference to a “three-pronged” approach sounds familiar, that’s because it is precisely what House Speaker Paul Ryan emphasized in his weekly press conference last Thursday: “We are going to repeal and replace Obamacare and we are going to do it with a three-pronged approach.” Meanwhile, Vice President Mike Pence took the message on the road and Senate Majority Leader Mitch McConnell has announced that he will push AHCA through the upper chamber quickly. In other words, the White House and congressional leaders are on the same page where repeal is concerned.
And this solidarity is producing results, as even the New York Times admits: “[T]he Republicans’ repeal campaign did gain momentum this past week as two House committees approved the legislation.” Some conservatives question the need for a three-stage approach, but the rules of the Senate make that approach necessary. Thus, AHCA will use the reconciliation process to kill Obamacare’s mandates and taxes, HHS Secretary Price will exercise his authority to eliminate its morass of regulations, and the few remaining changes are going to be passed via the normal legislative process.
It goes without saying, of course, that the “news” media have played up disagreements among Republicans over the best way to approach repeal. To exaggerate the dissension they continuously recycle statements from a few Republicans who seem to care more about publicity than policy. Senator Rand Paul, for example, garnered more coverage last week by pandering to this narrative than he has received since being trounced last year in the GOP primaries. But serious health policy experts, such as Avik Roy, call his characterization of AHCA as “Obamacare Lite” incoherent:
AHCA is nothing close to Obamacare Lite.… The bill would transform Medicaid into a modernized, dynamic insurance program: a policy achievement that would be akin to the 1996 welfare reform bill times 10. The bill would dramatically expand health savings accounts… a reform that would have the side benefit of lowering premiums.
The media have also disingenuously conflated the irresponsible rhetoric of publicity hounds like Senator Paul and the rigid positions of hard-liners like Senator Ted Cruz with more circumspect concerns of a few Republicans who support repeal yet worry that the wrong approach may adversely affect the stability of Medicaid for low income individuals. Four such Senators sent a letter to Majority Leader McConnell expressing doubts about an earlier version of the House plan. Senators Rob Portman (R-OH), Shelley Moore Capito (R-WV), Cory Gardner (R-CO) and Lisa Murkowski (R-AK) wrote:
The Affordable Care Act is not working for states or the federal government and must be repealed and replaced with a plan that reforms Medicaid and protects individuals and their families over the long term. However, the February 10th draft proposal from the House does not meet the test of stability for individuals currently enrolled in the program.
In keeping with the coordinated messaging campaign alluded to above, HHS Secretary Tom Price went on Meet the Press yesterday morning to explain that AHCA will not hurt such enrollees. The HHS Secretary was subjected to predictably partisan questioning from host Chuck Todd, who quoted a tendentious study by the left-leaning Brookings Institution predicting that 15-million people would lose coverage under the plan. Todd then demanded a guarantee that nobody would be worse off under the plan. Price explained that Obamacare had rendered millions worse off and continued:
I firmly believe that nobody will be worse off financially in the process that we’re going through. They’ll have choices from which they can select the kind of coverage that they want for themselves and for their family, not what the government forces them to buy. There’s cost that needs to come down, and we believe we’re going to be able to do that through this system.
Dr. Price also tried to explain to Todd that, as HHS Secretary, he would be dismantling Obamacare’s “regulatory apparatus” and that this would lower the cost of providing health care. Todd clearly didn’t have any idea what Price was talking about. He obviously doesn’t know that Obamacare itself gives the HHS secretary enormous discretionary power to make regulatory changes. In fact, Price issued a new regulation concerning Obamacare enrollment within days after being sworn in. This is the second “prong” of the GOP’s three-part approach to Obamacare repeal, and it is already underway.
The third stage of the GOP repeal process will be the most difficult, as it will involve normal legislation passed under regular order. But that will happen during the 2018 election season when there will be many vulnerable Democratic seats, so there may be more cooperation than usual from the other side of the aisle, if the GOP declines to form its customary circular firing squad over AHCA. And there is less chance of this than the Democrats believe. It is unlikely that the solidarity between the president, congressional leadership, and the HHS Secretary has been lost on rank-and-file Republicans.
In other words, these Republicans know that AHCA is rocketing toward a floor vote and that they will have to decide. As Paul Ryan put it during his news conference last Thursday, “It really comes down to a binary choice. This is the closest we will ever get to repealing and replacing Obamacare. The time is here. The time is now. This is the moment.” The bill will need 218 votes to pass in the House and 51 to pass in the Senate. After 7 years, how many Republicans will be ready to face his or her constituents, having cast the vote that prevented Obamacare repeal from going to President Trump’s desk?