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The things that need to happen for AHCA to pass aren’t yet happening

Paul Ryan sure has a lot of work to do.

Photo by Justin Sullivan/Getty Images
Andrew Prokop is a senior politics correspondent at Vox, covering the White House, elections, and political scandals and investigations. He’s worked at Vox since the site’s launch in 2014, and before that, he worked as a research assistant at the New Yorker’s Washington, DC, bureau.

Last week, I wrote about seven things I thought probably needed to happen for the American Health Care Act to get to President Trump's desk. So why don't we check in and see how things are going?

1. Trump decides he wants a win — and doesn't care about the bill's details: There's good news and not-so-good news here for Paul Ryan. The good news is that the president has been involved — he's made clear his support for the effort (though he could do more), he's taken calls with congressional leaders, and he's taken meetings with holdout members of Congress and conservative groups.

The not-so-good news is that the White House isn't just being a cheerleader and arm twister helping the AHCA get across the finish line. According to Politico and CNN, the White House is instead pushing Ryan to make the bill more conservative — potentially by phasing out the Medicaid expansion in 2018 rather than 2020 — in an effort to satisfy holdouts on the right.

That's a problem because House GOP leadership aides fear that deeper cuts could lose more votes from members concerned about coverage losses, as Jeremy Diamond reported last week. (I call those members the Coverage Caucus, since they're not all traditional moderates.) Ryan would've preferred to try to call conservatives' bluff, but that's harder to do now that Trump is apparently on their side. So we'll see what the president says at his rally tonight.

2. The CBO score must be good — or ignored: The score was, of course, far worse than expected. And Republicans aren't ignoring it — a few House members have already cited its estimates in explaining why they're opposing the bill. Major changes resulting in a much better CBO score will surely be necessary to get something through the Senate.

3. Industry groups and retirees must be pacified: No progress here — in fact, the American Hospital Association is urging its members to contact their representatives in opposition to the bill.

4. Conservative media and groups must hammer the holdouts: Nope — Breitbart is continuing to trash the House bill and Speaker Ryan, and the Drudge Report doesn't seem all that supportive either, as Oliver Darcy writes.

5. A deepening crisis in the individual marketplaces could add pressure to act: This situation hasn't changed in the past week — there are real problems, particularly in certain counties or states, but there's not yet a dramatic "collapse" like Republicans have predicted.

6. Conservatives cave, and cave, and cave: Nope — as mentioned, Trump seems to have instead strengthened conservatives' hand to demand more changes. I repeat: Considering the Senate math, it's hard to see how this thing passes unless conservatives cave a whole lot.

7. Moderate Republicans are won over somehow: Again, no — things seem to be going in the wrong direction here. For instance, Rep. Leonard Lance (R-NJ) defended the bill during markup and on MSNBC last week. Since the CBO score, though, he's changed his tune. "I do not want to vote on a bill that has no chance of passing over in the Senate," he told CNN.

Overall, then, the situation looks grim. Passing something through the House may still be possible (although there's no guarantee of success there). But a serious overhaul will be necessary to get Senate approval. So as Ryan contemplates his "manager's amendment" that could reshape the AHCA before a House floor vote, he'll certainly have a lot to think about.

Collapse and replace?

The GOP plan, at first, was "repeal and delay." When that proved unpopular, Republicans moved to a more traditional "repeal and replace."

But some Republicans are already thinking about a potential Plan C — something Sen. Lindsey Graham (R-SC) rather glibly dubbed "collapse and replace" on The Hugh Hewitt Show Tuesday.

  • GRAHAM: Here's what I would suggest to the President. Keep working hard. I want to work with you. I want to get to yes. But if it doesn’t work, if we can’t get there by ourselves, let it collapse. It is collapsing. Obamacare is a nightmare for the country. Democrats are not going to lift a finger to help President Trump. I would do collapse and replace if you can’t get a good, solid fix to Obamacare using reconciliation.

He's not the only one who's started thinking this way. Jeffrey Lord, one of CNN's in-house pro-Trump commentators, said today that he was "beginning to think" that "the best thing is to just step back and let it crash."

And, as I wrote earlier this week, Trump has indicated some sympathy for this viewpoint — one of his favorite talking points is that repealing Obamacare is a political loser for the GOP, since if they simply did nothing, Democrats would get the "blame" for the health market's woes.

It's not exactly a good sign for the AHCA that "how about we just do nothing" has reentered the Republican conversation. And it's not exactly a good look for Republicans to be openly embracing a strategy of letting Obamacare "collapse" — something that, if it did indeed happen, could greatly harm millions of people.

Furthermore, Bloomberg's Max Nisen argues that if any collapse does happen — and it's worth noting, CBO expects the individual markets in most areas to remain stable — it will likely unfold quite slowly, not spectacularly. So "collapse and replace" might work better as an excuse for doing nothing than as an actual strategy to pass a health bill.

Chart of the Day

Source: Kaiser Family Foundation

"Seventy-five percent of the public thinks Medicaid should continue to pay Planned Parenthood for non-abortion services, while 22 percent think all federal payments to the organization should be stopped." Read more results from KFF's poll here.

Today's health policy and politics reads

With research help from Caitlin Davis.

  • "The Lessons of Obamacare": "When economists in Washington say they want to control health care costs, they mean something like this: People should buy less health care, or cheaper health care, so that total spending on health care falls. When voters say they want to control health care costs, they mean something like this: Someone else should pay for my health care so I can purchase what I need without much financial strain." —Sarah Kliff and Ezra Klein, Vox
  • "Let’s Not Let the Republicans Make the Obamacare Replacement Debate About the Congressional Budget Office": "If you carve a huge chunk of revenue out of Obamacare and shift more subsidies to the middle class it should not be a surprise that the lower income folks will pay the price." —Bob Laszewski, Health Care Policy and Marketplace Review
  • "If Sean Spicer talked to someone on Medicaid, he'd probably find out they love it": "Researchers have consistently found giving people Medicaid improves their access to health care compared to those who go without insurance. This has been true in the primary-care and hospital settings. It’s also been true on self-reported measures of access to care. People even like their Medicaid, according to surveys." —Julia Belluz, Vox
  • "House considering nixing continuous coverage piece of health care bill": "While it was included in the bill to encourage young, healthy people to sign up for health insurance, the people who would be deterred from buying coverage because of the penalty would be healthier than those who would be willing to sign up. Sick people have more incentive to pay more for health insurance, as it's still cheaper than their medical bills." —Caitlin Owens, Axios
  • "White House May Let States Put Work Requirements on Medicaid Recipients": "The Trump administration will work with states that want to alter their Medicaid programs by imposing work requirements, premiums, emergency-room copayments and other changes, part of a Republican effort to give states more authority over the program’s implementation." — Stephanie Armour and Louise Radnofsky, Wall Street Journal

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