President Donald Trump returned home from his big foreign trip this weekend and immediately resumed tweeting strange opinions about Congress. If there is one thing that congressional Republicans just love, it is when Trump—who doesn’t know a single thing about the legislature, federal policy, or anything pertaining to the federal government that he runs—tweets about congressional strategy and policy. In none of his tweets can we ever figure out an understanding of the topic at hand or a duly considered policy purpose, including these newest ones. We may, however, be able to decipher what he heard in his most recent briefing from his legislative liaisons or envoys from the Republican congressional leadership.
After a brisk Saturday morning tweet storm about the “Fake News” and its lies, Trump offered the following opinion about health care reform, several months into the effort and after House Republicans had put their careers on the line grinding out narrow passage of a bill that no one liked:
I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead - the Republicans will do much better!— Donald J. Trump (@realDonaldTrump) May 28, 2017
The first half of this message is a policy directive Trump ought to have given congressional Republicans in, say, November, before they drew up and staked all of their—and his—limited political capital on a plan to do the opposite.
The House-passed American Health Care Act, according to the Congressional Budget Office’s analysis, would cut federal spending on health care by $993 billion over the next 10 years—mostly through cuts to Medicaid, as well as through a net decrease in refundable tax credit dollars for those on the individual market. If Trump believes that the key to making the American health care system “the best anywhere” is to “add more dollars to Healthcare,” he should now instruct Senate Republicans to abandon their own similar work and write a bipartisan bill that would “add more dollars to Healthcare.” (Or Trump is just flatly saying that the AHCA already does “add more dollars to Healthcare” relative to current law. This sort of propaganda by outright lying has been the party line thus far on the bill.)
Or Trump meant “add more dollars to Healthcare” in a narrower sense, addressed to the Senate. He could be instructing it to “add more dollars to Healthcare” than the House bill does—a very low bar. Someone may have briefed the president on the poor CBO score the final version of the AHCA received last week while he was abroad: It would result in 23 million more uninsured and higher premiums for older, lower-income, and sicker people. Getting into the weeds over this health care debate is worthwhile and necessary. The big-picture takeaway of the AHCA and the entire Republican health care reform effort, though, is that it would deprive tens of millions of health care by reducing federal spending on health care.
So perhaps someone told Trump not to worry about the CBO score, because the Senate could just spend more than the House bill did. The Senate likely will reshape the AHCA’s refundable tax credits away from an age-based allocation and toward one based on need, so that low-income seniors aren’t facing projected premium increases of 850 percent as they are under the House plan. Instead of just punching Medicaid in the face and walking away, as the House bill did, the Senate might punch Medicaid in the face, hand Medicaid a pack of frozen peas to contain the swelling, and then walk away. If the Senate decides to keep, in some form, the controversial deregulatory waivers in the AHCA that will result in some people with pre-existing conditions being unable to afford coverage, it could opt to spend significantly larger sums to fund high-risk pools or reinsurance programs to try to protect those very people. No Republican plan is going to improve on the Affordable Care Act’s coverage numbers, but these steps could at least mitigate the AHCA’s losses.
There’s a procedural snag, though, with “adding dollars” to the House’s health care framework: A budget resolution rule requires that the House reconciliation bill serve as a deficit floor for the Senate’s bill. In other words, the Senate bill must meet or exceed the AHCA’s $119 billion in savings. If Republican senators want to devote more money to people with pre-existing or chronic health conditions and substantially soften the House’s draconian treatment of Medicaid, it will have to consider something verboten, like leaving in place a modest tax on wealthy people.
Let’s say someone who understands Congress says this to the president. How might the president respond?
The U.S. Senate should switch to 51 votes, immediately, and get Healthcare and TAX CUTS approved, fast and easy. Dems would do it, no doubt!— Donald J. Trump (@realDonaldTrump) May 30, 2017
As always, it’s far from clear what this means.
The bill only needs a majority vote in the Senate for passage under the current approach, but how that occurs is restricted by the rules of reconciliation as described above. So, is the president calling for an end to the filibuster, so that Republicans can go the majority vote route without having to abide such rules? Or did he forget about reconciliation entirely? Could it be that he’s angry and spouting off nonsense?
And anyone who thinks Senate Republicans can get 51 votes—or 50, plus Vice President Mike Pence as the tie-breaker—on health care “fast and easy” hasn’t been paying attention to their inability to do exactly that. (Sure, if you could permanently cut taxes without having to make up the lost revenue with 50 votes—as is now forbidden by reconciliation rules—Republicans probably could find a way to do that “fast and easy.”) But Senate Majority Leader Mitch McConnell will never, ever attempt to “nuke” the legislative filibuster, anyway. As for Trump’s belief that Democrats wouldn’t hesitate to do so, that’s belied by their preservation of the legislative filibuster during the eight years they controlled the Senate from 2007 to 2015, as well as the 32 Democratic senators who recently signed a petition supporting its continuation.
Health care reform is hard. Partisan health care reform is harder. Doing partisan health care reform under reconciliation rules is even harder, but reconciliation isn’t the big problem here. The way for Republicans to get a health care law enacted “fast and easy” would be to write one that voters like.
If Trump were even modestly well-versed in the issue, he would understand that the holdup in Congress isn’t a matter of congressional Republicans lacking willpower to make the aggressive tactical move here or there. That this toxic effort is somehow still alive is an incredible demonstration of ideological and political willpower suppressing such considerations as public approval. The AHCA is an unpopular bill, the Senate is following a similarly unpopular approach, and Trump signed off on all of it. What he actually wants done now is a mystery even to him.