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Let’s speculate about what the Kansas special election means for health care

Republicans barely held on in Kansas. That’s bad news for Trumpcare.

Photo by Mark Reinstein/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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The big political news last night was the Kansas special election in the state's Fourth Congressional District, where Republicans kept a seat they've held for 20 years — but by such a narrow margin that it's surely giving other Republicans the jitters.

But what does it mean for the American Health Care Act, the Republican bill that stalled out before Congress went home for two weeks but that Trump is still swearing to revive? Let's think it through.

The new Republican Congress member, Ron Estes, is a potential yes vote for Trumpcare. That's good news for House leaders and Trump.

Estes said after his election that he would go to Washington intending to repeal Obamacare. He has expressed some concerns about the AHCA before, but so have other rank-and-file members who ultimately got on board.

It's hard to imagine a freshly minted Congress member who has had kind words for the president bucking him on such a crucial issue. Trump even singled out health care as one reason for Kansas voters to back Estes.

The bill still needs the same number of votes for now — 216 — but Estes could get it one vote closer to that magic number.

But the slim margin could make on-the-fence Republicans nervous. Trump won Kansas's Fourth Congressional District by 27 points just a few months ago, and Mike Pompeo, who vacated the seat to become Trump's CIA director, won by more than 30. Estes beat a no-name Democratic candidate by only 7 last night. That's a 20-point swing.

Arguably, part of that dynamic is specific to Kansas, where GOP Gov. Sam Brownback is uniquely unpopular and easily linked to Estes, his state treasurer. But the message to House Republicans nervous they could be in jeopardy in 2018 seems clear.

Here's how the math works out. A smart Republican lobbyist told me last month that Trumpcare was always going to lose many, if not all, of the 23 House Republicans who represent districts that Hillary Clinton won in November.

That already gave the bill a very slim margin for error — it could only lose 22 Republican votes and still pass, assuming Democrats were united against it.

But now, after the Kansas election, what if you're a Republican in a district that Trump won by, say, 5 points? By the New York Times's count, 87 House Republicans were undecided, concerned, or outright no votes on Trumpcare the first time.

Are any of them going to look at last night's election, where a historically rock-solid Republican district turned into a single-digit race, and decide supporting the AHCA is the right move for their political survival?

Nonetheless, Trump swears health care reform isn't over. Look, until we have an official deal, be skeptical of any alleged action on health care. (Here's the latest from Axios on what's being discussed.)

But Republicans can't be seen as giving up on their seven-year quest to repeal Obamacare, even if there is no sign that the policy snafus that stopped their bill have been resolved.

So we're going to get comments like this one from Trump in an interview with Fox Business, in which he ties health care to tax reform:

"I have to do health care first. I want to do it first to really do it right.

"We’re saving tremendous amounts of money on health care when we get this done, number one, and most importantly … we’re going to have great healthcare, and all of that savings goes into the tax. If you don’t do that you can’t put any of the savings into the tax cuts and the tax reform."

(If you want some other tea leaves to read, House Speaker Paul Ryan is leaving the country next week. So nothing seems imminent.)

Chart of the Day


Speaking of which: The conventional wisdom is coalescing around the idea that true Obamacare repeal is dead. The venture capital firm Venrock recently surveyed more than 200 health care professionals to get their take. The results were pretty clear.

Kliff's Notes

With research help from Caitlin Davis

  • "What Trump Can Do Without Congress to Dismantle Obamacare": “House Republicans left for spring break last week, without reaching a deal to repeal and replace the Affordable Care Act. Their bill to overhaul the health care system collapsed on the House floor last month, amid divisions in the caucus. Even without Congress, however, President Trump has the authority to modify important provisions of the health law, including many that House Republicans sought to change or repeal. Here are some examples of actions he could take (or has already taken).” —Haeyoun Park and Margot Sanger-Katz, New York Times
  • "Why Your Choice of ‘In Network’ Doctors Could Get Smaller in 2018": “In a Federal Register filing in February, the Department of Health and Human Services announced that determinations of network adequacy would be left to the states going forward. States that don’t have the capacity to set network adequacy on their own would be expected to revert to the standard used in 2014, before the Obama administration added additional requirements.” —Rob Garver, Fiscal Times
  • "In ‘Stealth Move,’ Mich. Refines Vaccine Waivers, Improves Rate Among Kids": “Just three years ago, Michigan had the fourth-highest rate of unvaccinated kindergartners in the nation. But when a charter school in northwestern Traverse City reported nearly two dozen cases of whooping cough and several cases of measles that November, state officials were jolted to action. Without much fanfare — or time for opponents to respond — they abandoned the state’s relatively loose rules for getting an exemption and issued a regulation requiring families to consult personally with local public health departments before obtaining an immunization waiver.” —Guy Gugliotta, Kaiser Health News

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