Under pressure from the Trump administration, House Speaker Paul Ryan and his allies are still fighting to pass the American Health Care Act, more than a month after a first attempt crashed against a wall of grassroots opposition and reticent Republican lawmakers. (Update, May 4, 2017, at 2:25 p.m.: The bill passed on a 217–213 vote.)
This latest push centers on two amendments, one to win over conservative opponents, the other to win over more moderate holdouts. The first amendment, crafted by New Jersey Rep. Tom MacArthur and introduced in April, would allow states to waive key requirements of the Affordable Care Act. Under MacArthur’s proposal, states could opt to allow insurers to sell plans that lacked essential health benefits such as maternity care and mental health services and let them charge sick people more for health insurance than those with fewer complications and conditions. The MacArthur amendment satisfied demands from House Freedom Caucus, winning key conservative support.
At the same time, these provisions alienated more moderate Republicans who wanted help for those Americans with pre-existing conditions. Which brings us to the second amendment, introduced by Reps. Fred Upton of Michigan and Billy Long of Missouri. This proposal would open $8 billion in funding for state-crafted high-risk pools to help insure individuals with pre-existing conditions. With this amendment attached, Upton—a surprise no vote on the bill earlier in the week, but now a yes—predicted the AHCA would pass the House.
After seven years of promising to repeal and replace the ACA, Republicans are certainly desperate to pass something. So desperate that they are now sprinting for the finish line as quickly as possible, forgoing customary analysis from the Congressional Budget Office to avoid controversy or second thoughts from hesitant members. These amendments—which it seems would likely worsen coverage for many—don’t change the fact that the AHCA is a political and policy disaster waiting to happen—a disaster that could undo the Republican majority in dramatic fashion.
To start, there’s the fact that the Upton amendment doesn’t do much to fix the basic problem of the AHCA and its treatment of Americans with pre-existing conditions. As my colleague Jordan Weissmann notes, that $8 billion would likely not be enough to make up for the current shortfall needed to fund the pools adequately. Indeed, it’s not even clear that this money will be used for high-risk pools. According to one report, the $8 billion is there to pay the law’s insurance penalty for consumers who were priced out of the health market on account of pre-existing conditions and thus couldn’t maintain coverage. It’s less a subsidy to individuals and more a giveaway to insurers, who could charge high penalties knowing the government will recoup the cost, to say nothing of their newfound freedom to sell junk plans. What’s more, Weissmann points out, the Upton amendment may encourage consumers to wait to buy insurance until they are sick (again, the government will pick up the penalty), destabilizing health care markets.
All of this is on top of the fact that the basic structure of the AHCA hasn't changed. It still cuts Medicaid, still defund subsidies for health insurance, and still presumably ends health insurance for more than 24 million people over the next 10 years (we can’t say for certain because, again, the Republicans still don’t have a CBO score). And all of this is in service of massive tax cuts for the wealthiest Americans, the overriding priority of Ryan and much of the House Republican caucus.
The original AHCA failed because it was an unworkable and unpopular policy, opposed by huge majorities of the public. Ryan’s boosterism aside, this new AHCA is still unworkable and, in all likelihood, still unpopular—the original bill was polling at 17 percent. Although these changes may have made the bill more palatable to conservatives, there’s no reason to expect them to move the numbers to anywhere near majority support. And that unpopularity matters: Following its introduction in March, the AHCA sparked a steep and sustained decline in Trump’s standing, which damaged the Republican Party writ large and may have contributed to the surprise strength of Democratic congressional candidates in Kansas and Georgia. House Republicans can continue their push for a bill, but they have to know that they risk genuine political disaster, to say nothing of the human costs of their bill.
Yes, if it passes the House, President Trump will celebrate the “win,” and Ryan will declare a victory for ordinary families (who can now presumably live life without the burden of affordable health insurance). But the truth is there’s no spinning a bill that yanks health insurance from tens of millions of people. And even if it dies in the Senate, killed by Democrats and wary Republicans, the House majority will be on record as supporting legislation to plunge countless families into terrible hardship, in a country where most people see health insurance as a right, even if they disagree on how best to deliver it. If it leaves the House, the AHCA may well become the vehicle Democrats use to retake the chamber and turn that power against President Trump. It’s true that the party’s failure to live up to its nearly decadelong promise to repeal and replace Obamacare might potentially deflate the party’s base in 2018. But passing an incredibly unpopular bill does not seem like the wisest solution to that problem.
House Republicans are dancing with disaster. The AHCA was already a quagmire that threatened to derail their entire legislative agenda. And their fight to pass it is on behalf of a president who shows no particular loyalty to their priorities or political prospects, backed by a speaker in the grips of an ideological crusade. The best play, at this stage, would not be to push through. It would be to throw in the damn towel and cut their losses.