The rollout of the House GOP’s Obamacare repeal bill has been very rocky indeed. Major industry associations, conservative activist groups, health policy wonks, the AARP, and the entire Democratic coalition have all panned the American Health Care Act. Other than the US Chamber of Commerce and Republican leadership, enthusiastic supporters are few and far between. The history of congressional politics suggests that something opposed by so many powerful actors is unlikely to become law.
Still, with House GOP leaders professing optimism that they can get a bill through their chamber this month, and so much of politics’ conventional wisdom being upended of late, it’s worth asking — what would have to happen to prove them right?
I’ve made my best effort to construct a political scenario in which Obamacare repeal and replace does pass. While technically not all of these things would have to happen to bring about that outcome, my guess is that most of them would. If these things start happening soon, it’s good news for AHCA; if they don’t, well, the state of Obamacare looks strong.
1) Trump decides he wants a win — and doesn’t care about the bill’s details
Republicans on the Hill need two things from President Trump. First, they need him to push hard for a bill. He needs to make unmistakably clear that he wants them to pass the AHCA, and that failing to do so would be a major defeat for his presidency. To get that message across, Trump needs to be both twisting arms and helping make the case for the bill to reluctant members of Congress.
Second, and a bit paradoxically, GOP leaders need the president not to make his own demands on policy details. That’s because his stated preferences on health policy are rather different from those of congressional Republicans — he’s promised that his health plan would provide “insurance for everybody” even if they couldn’t afford it, that he wouldn’t cut Medicaid, and that he’d tackle high prescription drug costs.
The GOP’s best shot for success is if Trump decides he wants a big legislative achievement badly enough that he essentially doesn’t care about its actual details. Then he could be both cheerleader and arm twister, without adding new and likely impossible-to-meet demands to the negotiation process. (Of course, this strategy could come back to harm him in the long term if the bill turns out to have disastrous effects, but in terms of getting something done now, it’s Republicans’ best bet.)
2) The CBO score must be good — or ignored
Many members of Congress haven’t yet taken a position on the AHCA and have said they’re waiting to see the Congressional Budget Office’s estimates on how it will affect spending, coverage numbers, and premium costs. A good CBO score on all those fronts would obviously be great news for the bill.
But early analysis suggests the AHCA would lead to millions losing coverage and average costs per individual market enrollee rising. Also, there’s no evident way to pay for the bill, which means it will either swell the deficit or compensate with draconian Medicaid cuts.
A bad CBO score would likely cause moderate members to blanch at its effects. To solve this problem, Republicans have two options: Either they try to appease CBO by making major changes to their bill or they try to discredit the office altogether.
On the latter front, Politico’s Jennifer Haberkorn reports that leading Republicans are preemptively aiming criticism at CBO already, and that the Trump administration’s Office of Management and Budget may release its own projections of the AHCA’s impact, which will likely be far rosier than CBO’s. (That is, they’ll come up with alternative facts.) If all this provides enough cover for moderate and cost-concerned members to ignore CBO’s red flags, that will be helpful for the bill’s prospects.
3) Industry groups and retirees must be pacified
Doctors, hospitals, and retirees are three of the most powerful interest groups in the country. They’re very popular, they’re in every congressional district in the country, and their representatives in the House and Senate are keenly responsive to their concerns.
Currently, every major doctor and hospital group is against the AHCA. So is the AARP — it’s created a video saying the bill would institute an “age tax” making health insurance more expensive for people near retirement age. If these three interests lobby hard against the bill, it’s in very serious trouble.
Democrats calculated in 2009 that it was essentially impossible to pass a major health reform bill without winning over these constituencies, so they worked closely with their major lobbying associations to ensure their concerns were addressed. Republicans will likely have to do something similar for their own effort. Though they may never win enthusiastic support from any of the groups, at the very least they need to temper their opposition somewhat.
4) Conservative media and groups must hammer the holdouts
Quieting interest group opposition isn’t enough. For Congress to pass something as sweeping as comprehensive health reform, there needs to be affirmative pressure on them to do so.
Theoretically, that pressure would come from conservative activist groups and media figures eager to see the hated Obamacare gone at long last. If groups like Heritage Action, talk radio hosts like Rush Limbaugh, websites like Breitbart, and TV networks like Fox News were all praising the Republicans’ repeal-and-replace plan, that would put a lot of pressure on holdout GOP members of Congress to go along.
But currently, many of them are trashing the House GOP’s plan for not being conservative enough — even though most analysts already view it as too conservative to pass the Senate. So right now their energies are being put into criticizing the bill rather than building support for it. If something’s going to pass, that has to change.
5) A deepening crisis in the individual marketplaces could add pressure to act
One potential element that could scramble the politics of all this is a potential crisis in the individual insurance markets. Already, these markets have been particularly fragile in some counties or states, with insurers pulling out because of high costs or overly sick populations. In many, only one or two insurers are still participating in Obamacare’s exchanges. One company, Humana, withdrew entirely last month, and Aetna and UnitedHealth mostly withdrew last year.
It is possible this situation could worsen if other major insurance companies decide to quit the exchanges. That could put added pressure on swing Republicans and even vulnerable Democrats to do something and pass some sort of health reform bill.
Still, one problem here is that Republicans would have to argue that their solution would improve this situation, and as currently crafted, some experts think it would instead make the risk of a death spiral worse.
6) Conservatives cave, and cave, and cave
There’s no way around it — if any Obamacare repeal bill is going to pass both houses of Congress, conservatives will have to make some compromises they’ll find very unpleasant.
This is particularly true in the Senate, where any bill would need to hold on to 50 out of 52 Republican senators if Democrats remain united in opposition. And the senators who will in the end be the swing votes are already sending a clear signal that the AHCA is too conservative for them.
A bloc of GOP senators is already demanding the Medicaid expansion be protected. A couple don’t want the defunding of Planned Parenthood in the bill. Sen. Susan Collins (R-ME) recently said her goal is to have “more individuals covered than in the ACA.” Sen. Bill Cassidy (R-LA) wants to ensure a comparable number of people are covered, and that the bill doesn’t add to the debt.
If conservatives want Obamacare repealed and replaced, they need to win over these senators. But currently they’re demanding their own alterations to the bill that are in many ways irreconcilable with the moderates’ goal of expanded coverage.
Many have speculated that these conservatives are largely bluffing, and that when push comes to shove they will vote for the AHCA rather than let Obamacare stay in place unchanged. Perhaps — but if conservatives don’t cave, it’s hard to see a path for this thing.
7) Moderate Republicans are won over somehow — through concessions, through persuasion, or through fear
If conservatives are brought on board, then — as with the Affordable Care Act, the stimulus, the Bush tax cuts, and pretty much every big controversial bill — the drama will shift to whether a few key swing votes can be won over.
The 60th and deciding Senate vote for the Affordable Care Act in 2009 came from then-Sen. Ben Nelson of Nebraska, the most conservative Democrat in the chamber. He and other moderates like former Sens. Joe Lieberman (I-CT), Mary Landrieu (D-LA), and Evan Bayh (D-IN) all had to be won over to get the bill over the finish line.
They demanded various concessions in exchange for their support — for one, the public option was famously dropped from the bill. Nelson was offered special funding for Nebraska Medicaid recipients in what became known as the Cornhusker Kickback. (It was dropped from the final version of the law.)
But another key to winning the support of these moderates despite evident political peril was that they were convinced the bill would be a good one. President Obama and other leading Democrats made the case that the Affordable Care Act would help millions of people, and that once it was put into practice, people would like it. They were persuaded they were doing a good thing.
Another factor that could urge swing vote Republicans to get in line is fear. Many of them will already be fearful of potentially losing their seats to Democrats in a general election if they vote for the bill. So one potential way to counter that is by stoking a related fear of primary challenges — making them fear the primary more than the general.
This interacts with a few previous items on this list. Swing members’ fear of a primary is more likely to exceed their fear of losing in the general if President Trump is engaged and demanding their fealty, and if conservative media and activist groups are pressuring them to support a bill. They may in the end calculate it’s safer to go along with most others in the GOP, rather than be one of the few responsible for tanking the president’s top legislative priority.
And there’s one other possibility: that for even the swing vote Republicans, much of what we thought used to matter in congressional politics — the lobbying of industry groups, the analysis of policy experts, the fears of constituents, the desire of members to help shape the bill — in fact doesn’t amount to a hill of beans anymore. That instead, partisanship, the president’s demands, and long-held talking points trump all. That regardless of what Obamacare’s replacement even is, and what its consequences would be for millions of Americans, all Republicans care most about is being able to say they repealed it, and being able to deliver President Donald Trump a win.