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The GOP's next legislative trick will be bringing AHCA back from the dead

Congressional GOP want another try at Obamacare repeal. There’s just one big problem.

Photo by Mark Wilson/Getty Images

House Speaker Paul Ryan on Friday regarding repeal: "We’re going to be living with Obamacare for the foreseeable future."

Ryan today: Maybe not.

"The way I would describe the meeting we just had with our members is we are going to work together and listen together until we get this right," Ryan told reporters after a meeting with his conference in the Capitol.

It's a remarkable about-face from just 96 hours ago when, after he had to yank his bill, Ryan held a press conference and conceded, "Obamacare is the law of the land."

Other Republicans say they are on board with the new push. (We surveyed some key Senate Republicans. Their comments are below.) But the looming question is still whether Ryan can put together a politically viable plan.

What Republican legislators are saying: They still plan to work on Obamacare repeal.

Ryan wasn't the only Republican leader who came out of that meeting more bullish on keeping the Obamacare repeal-and-replace fight going.

"We promised that we would repeal and replace Obamacare, and that's exactly what we're going to do," House Majority Leader Kevin McCarthy (R-CA) told reporters after the meeting.

My colleague Jeff Stein, meanwhile, was across the Capitol talking to Republican senators — and they too were generally enthusiastic about doing something to keep the health care fight alive, possibly even drafting their own bill. Here's what they told him:

  • Sen. Lamar Alexander (R-TN): "I don't speak for the House, but there's a sense they were pretty close when they stopped last week. The sense of urgency is the millions of Americans who will be without health insurance, stabilizing the individual market. We said we would do it."
  • Sen. Pat Roberts (R-KS): "Obviously we're going to have to do something because our health care system is like Thelma and Louise: They drove it off the cliff, and we need to stop that care."
  • Sen. Orrin Hatch (R-UT): "I think the Senate is going to have to move out on that. I’d love to see the House do a vote on it, because they feel very deeply. We may have to move out ourselves if they don’t."

What Republicans legislators are missing: a new health care plan.

Let's be clear: There are plenty of things Republican legislators want to do. There are plenty of things Democratic legislators want to do too. But there is a whole lot of space between setting a legislative goal and achieving it.

Crucially, legislators have not offered up a health care bill that could do better than the American Health Care Act, which Ryan had to pull from a floor vote at the last minute because it couldn't garner enough support.

This is going to be really, really hard — perhaps impossible.

There were two groups within the Republican Party that opposed AHCA. One was the right-wing Freedom Caucus, which said the bill didn't do enough to dismantle Obamacare's coverage expansion and insurance regulations. The other was more moderate conservatives who said the AHCA did too much to take apart the coverage programs. Finding a bill to satisfy both camps is going to be a huge struggle.

This helps explain why Senate Majority Leader Mitch McConnell is a whole lot less enthusiastic about pursuing Obamacare repeal and replace than his rank-and-file members. "Our Democratic friends ought to be pretty happy ... because we have the existing law in place," he said in a Tuesday press conference. "And I think we're just going to have to see how that works out."

My favorite unintentionally revealing quote of the day: Of all the senators Jeff spoke with, it was Sen. John Kennedy (R-LA) who gave what I thought to be the most revealing answer about where Republicans stand right now on the health care debate.

"I think the main area of consensus is that Obamacare sucks and we can do better," Kennedy said.

Kennedy's view that the main area of consensus is "Obamacare sucks" says a lot about where Republicans are on health care right now. The party knows it doesn't like Obamacare — that much is clear. Republicans campaigned against the health care law in 2010, 2012, 2014, and 2016. They have made their views known.

But beyond that ... it's not entirely clear what the Republican Party stands for on health care. The "we can do better" part has never been spelled out.

With the AHCA, it was never clear what exactly the goal was. It wasn’t expanding coverage — we learned that from the Congressional Budget Office report. It wasn’t reducing deductibles, as legislators had promised. And it wasn’t deregulating the insurance market; that wasn’t a goal Republicans could achieve through the reconciliation process they planned to use to pass the AHCA.

Until Republicans agree on a definition of what "better" looks like, they're going to struggle mightily to pass any bill.

Medicaid expansion watch: Kansas legislature passes bill, Virginia Gov. McAuliffe plans new push

The failed Republican health bill has had a surprising side effect: encouraging more states to explore the possibility of Medicaid expansion. Given that Obamacare seems to be here to stay — at least for the time being — governors and state legislators are looking at the program that covers low-income Americans with renewed interest. Here's a quick update on two states I'll be watching closely in coming weeks:

  • The Kansas legislature passed a Medicaid expansion bill. It now goes to the desk of Republican Gov. Sam Brownback, who is expected to veto it. The big question now is whether the Kansas legislature has the two-thirds majority needed in both the Senate and House to override that veto. Medicaid expansion would need 27 votes in the 40-member Senate and 84 votes in the 120-member House. It received 25 votes in the Senate and 81 votes in the House, meaning the bill is just a few votes shy of a veto-proof majority — but not far off.
  • Virginia Gov. Terry McAuliffe will make another push for Medicaid expansion — but knows it won't be easy. The Democratic governor has already made many attempts at Medicaid expansion – in 2013, 2014, 2015, 2016 ... basically every year he has served as Virginia governor. Each time, the state's Republican-controlled House of Delegates hasrebuffed those efforts. I spoke to McAuliffe Tuesday. He acknowledged that the odds are long, but the context around this particular expansion push could be in his favor. "You've seen Kansas, Georgia, North Carolina now making noise about expansion," he said. "I'm going to be surrounded by Maryland, West Virginia, and North Carolina — three states who I compete with for business who will have a healthier workforce. It will be a strategic disadvantage not to expand." Stay tuned for my full interview with Gov. McAuliffe on Vox tomorrow.

Chart of the Day

Sarah Frostenson / Vox

If Trump sabotages Obamacare, rural America will suffer the most. My colleague Julia Belluz ran the numbers and found that the places that have just one insurer selling on the marketplace are mostly counties that supported Trump in the 2016 election. "Obamacare is having trouble in rural areas," Northwestern health economist Craig Garthwaite tells her of these areas. "But that’s been a story of health care for the past 15 years. Providing rural health care is really tough." Read their conversation.

Kliff’s Notes

With research help from Caitlyn Davis

  • "After GOP Bill’s Failure, Health-Law Lawsuit Takes Center Stage": “The case could drag out for years. But if the Trump administration settles the suit and drops the appeal, payments would cease and insurers would likely increase premiums or abandon the exchanges. The payments would otherwise amount to roughly $130 billion from 2017 through 2026, according to the Congressional Budget Office. If the administration ended the payments, Congress would have to approve funding if lawmakers decided they wanted the subsidies to continue. That could be a tough sell because many Republicans are still calling for the ACA to be struck down.”—Stephanie Armour, Wall Street Journal
  • "Ryan Signals GOP Won’t Try to Defund Planned Parenthood in Spending Bill": “Rather than include a 'defund Planned Parenthood' provision on the upcoming bill to fund the federal government, the Wisconsin Republican said Republicans still plan to use their budget reconciliation framework to overhaul health care to stop federal money from flowing to the women’s health service provider. ‘We think reconciliation is the tool because that gets it in law,’ he said, referring to the budget tool that requires just a simple majority in both chambers to reach the president’s desk. ‘That’s the way to go.’” —Eli Yokley, Morning Consult
  • "Executive order lays out blueprint for Trump opioid commission": “The panel’s mission would be to identify federal funding streams that could be directed to address the crisis, for everything from medical treatments to long-term support services. The commission would also aim to identify areas in the United States with limited treatment options, review ways to prevent opioid addiction — including possible changes to prescribing practices — and consider changes to the criminal justice system to provide support for incarcerated individuals after their release from prison.” —Dylan Scott, Stat News

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