WASHINGTON – House Republicans finally passed a healthcare replacement bill on Thursday – the first piece of major legislation to pass in a chamber of Congress during the Trump presidency.
The bill is both hugely consequential and somewhat anticlimactic, though, given that it’s likely to be overhauled in the Senate and faces a completely uncertain fate both there and in a potential House-Senate negotiation.
But what happened Thursday will reverberate for months – maybe even in November 2018. Let’s go over some winners and losers.
House Democrats/Democratic ad-makers
The bill passed Thursday was a veritable smorgasbord of easy ads for Democrats to run against the dozens of vulnerable House Republicans who voted for it. And the Democratic ad-makers who get paid to use these lines should probably do so at a healthy discount.
A few that I foresaw in my piece about how this bill impacts the GOP in 2018: “Congressman XYZ voted to take 24 million people off health insurance,” “Congressman XYZ voted to cut coverage for pre-existing conditions,” “Congressman XYZ voted to raise premiums by 750 percent for low-income senior citizens.” Republicans will dispute all of these claims, but they are all substantiated in what the GOP passed Thursday and how the Congressional Budget Office scored a previous version of the bill.
Paul Ryan’s speakership (today)
As The Post’s Paul Kane wrote, it was a shot in the arm for the House speaker in that it showed he can deliver votes on a tough bill. Kane: “No one publicly spoke about it, but there were whispers that some or all of the House leadership team would fall if the legislation came up short. The fate of Ryan and his lieutenants hovered just beneath the surface – until Trump, with Ryan at his side, cracked a joke about it.”
That joke, in which Trump acknowledged the rumors but then called Ryan a “genius,” probably oversold how great a moment this was for Ryan (for reasons we’ll get to), but for now, Ryan got it done in the face of some very tough odds.
Rep. Tom MacArthur
If you didn’t know about the moderate second-term Republican from Toms River, New Jersey, until this week, you do now. He brokered the deal that got the conservative House Freedom Caucus – all but one of whose members supported this bill – on board after it balked at the previous version. How he did it: By proposing an amendment that allowed states to request waivers for things like the pre-existing conditions mandate and to instead create “high-risk pools.” That would allow insurers to potentially charge these people more, which the GOP addressed by adding $8 billion in funding for the high-risk pools.
Experts are skeptical that will prevent people with pre-existing conditions from paying significantly more for their care, which is a major, major caveat in all of this. But MacArthur, whose daughter was born with severe health issues and died at 11 years old, proved a particularly potent messenger for fellow Republicans on a very difficult proposal. It will now be up to the GOP to make sure the proposal, should it become law, isn’t as harmful to vulnerable Americans as critics fear.
Government health care
Remember when Republicans were going to repeal Obamacare? Yeah, this bill doesn’t do that – not even close. The GOP made that promise for four consecutive elections and reaped the benefits, and then it basically just tinkered with reforming Obamacare.
And all the while, the party that once decried government health care suddenly drifted toward acknowledging that it’s the new reality. Even the House Freedom Caucus, the group of Republicans most adamantly opposed to Obamacare, threw in the towel.
“We made a promise to the American people to repeal Obamacare and replace it with policy that brings down costs,” it said in a statement. “While this legislation does not fully repeal Obamacare, it’s an important step in keeping that promise to lower health care costs.” That statement was unthinkable a year ago – and really even three months ago.
And then you’ve got President Donald Trump, who decided on Thursday night, after the House GOP’s big victory for conservatism and the free market, to praise Australia’s government-run health care system. It’s a new era.
Poorer, older people and people with pre-existing conditions
Whatever ultimately comes of this bill – if anything – the fact is that Republicans are pursuing something that throws into doubt the coverage of tens of millions of Americans and the affordability of health care for older and poorer people and those with preexisting conditions. Those people got benefits from Obamacare, which is the law of the land, and the GOP may scale back those benefits to drive down health care costs overall.
The bill was passed without an updated score from the Congressional Budget Office, but the score of the previous bill showed 24 million fewer people would be insured by 2026 and premiums for senior citizens with annual income of $26,500 rising more than sevenfold to $14,600 per year. The bill would also phase out Obamacare’s Medicaid expansion and other key parts (which NPR summarizes here). The CBO said the bill would not increase overall costs, but mostly because it would benefit younger, healthier people while raising costs for older, sicker people, some of whom would be priced out of insurance.
The GOP dismisses those scores, but even the White House acknowledged this week that the impact of the pre-existing conditions change cannot be known – which is a scary prospect for those depending upon it.
Paul Ryan’s speakership (after the 2018 election)
However much Ryan might have saved his job and bolstered his status for the 115th Congress on Thursday, he very likely hurt the GOP’s chances of retaining the majority – and thus his own prospects to remain speaker – for the 116th Congress. I’m not sure how much either of those were really in doubt, but Democrats’ chances of taking back the House are certainly better on Friday morning than they were on Thursday morning – for the reasons described in “Democratic ad-makers” above.
The fact is that the old version of this bill polled horribly (62-29 percent against in a CBS News poll and 56-17 against in a Quinnipiac poll), and then Republicans monkeyed with a pre-existing conditions clause that between 70 and 87 percent of Americans seemed to prefer to keep as is. This bill already appears to be more unpopular than Obamacare ever was, and arguably dozens of Democrats wound up losing their seats because of Obamacare.
Democrats need to win 25 seats to regain the majority, and 24 House Republicans come from districts where Trump didn’t get a majority of the vote.
Senate Republicans
You almost get the sense that Senate Republicans hoped this day would never come – the day the House actually passed something and put the onus on them to pass something, too. They’ve already signaled they won’t vote on the House’s bill but will instead come up with their own version. But even passing that will be a momentously difficult proposition, given that some moderate GOP senators have signaled they won’t vote for something that increases the number of uninsured Americans, and others also have very serious reservations.
Striking the right balance to pass something in the Senate (where the GOP has only 52 votes), and then trying to reconcile two bills that will very likely have passed with bare majorities, is a daunting task.
The CBO
Republicans used to preach the virtue of understanding bills and knowing their impacts before voting on them. That was when Democrats were in power, of course. With their vote Thursday, House Republicans yet again suggested they have little regard for the nonpartisan Congressional Budget Office’s scores of their legislation, not even waiting for an updated one. And GOP leaders apparently got their members to shrug off a brutal CBO report of the old version of their health care bill to vote for this one.
