clock menu more-arrow no yes mobile

Filed under:

What the Obamacare debate can teach us about Trumpcare

Mark Wilson / 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.

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

Everybody is waiting to see if House leadership and the White House can convince enough Republican moderates to support the American Health Care Act and get the bill out of the lower chamber.

If you remember the slog to pass Obamacare, you might be feeling some déjà vu.

In both cases, the centrist wing of the party in power proved to be the final barrier to passing a health care plan in the House. In 2010, it was the Blue Dog Democrats. Today it's the Tuesday Group.

The similarities are striking. In 2010, about 50 Democratic lawmakers were part of the Blue Dog Coalition. The Tuesday Group, composed of the moderate House Republicans, also claims about 50 members.

Winning the centrist vote was crucial to Obamacare's passage, though 34 Democrats still voted against it. This time around, House leaders are also likely to lose moderate votes — but they can live with that, as long as they can corral the 216 votes they need to pass the bill.

When it comes to the centrists, a holdover argument from the Obamacare debate could work for the AHCA — but there's also an important difference between the two scenarios.

As then-Speaker Nancy Pelosi sought to bring centrist Democrats in line, she had a pretty compelling message: We've been talking about health care reform for decades. This is our one chance to do it.

Here's how Brendan Daly, who was a Pelosi aide at the time, described the pitch to me: "If not now, when are we ever going to do this?"

"It's the only time we can actually get this done," he said. "That’s what drove a number of the members to support it."

If you listen closely, you can hear Republican leaders applying the same pressure publicly.

It's the inverse of Pelosi's pitch: We've been talking about repealing Obamacare for years. If not now, when?

"We promised that we would do this," House Speaker Paul Ryan said Thursday. "If you violate your promise, if you commit the sin of hypocrisy in politics, that’s the greater risk.”

That was a popular sentiment around the Capitol, as leadership scrounges for the final votes it needs to pass the AHCA.

"This is my great concern: that if we don't get this done now, we may be losing our last chance," Rep. Tom MacArthur, the moderate Republican from New Jersey who negotiated a deal with the conservative Freedom Caucus that gave the bill new life, said.

I asked him if that was the pitch he's been making to his peers.

"Of course," he said. "That's been the whole motivation for me in proposing a solution."

The conventional wisdom is moderate House Republicans could lose their seats if they back the AHCA, and that's holding them back. But Ryan tried to turn that logic around when he was asked about that risk on Thursday.

"I think people’s seats are at risk if we don’t do what we said we’d do," he said.

But that brings us to the crucial difference between the ACA and the AHCA, which could make it more difficult for the Republican bill to win over centrists.

Last time, we were talking about expanding health coverage to millions of Americans. This time, millions of Americans could lose coverage.

You can have philosophical problems with Obamacare, and many Blue Dogs clearly did. But they were being asked to vote on a bill that the Congressional Budget Office estimated would lead to 32 million fewer Americans being uninsured (a rosy estimate, but that was the figure at the time.)

Moderate Republicans, on the other hand, are being asked to vote for legislation that CBO says would lead to 24 million more Americans being uninsured.

It's clearly weighing on many of them, which is why my colleague Andrew Prokop dubbed these lawmakers the Coverage Caucus. Much of the movement on Thursday seemed to be moderates coming out against the new bill for this reason.

"I think that is the absolute difference here," Daly said. "This has real consequences for people."

Again, one could make the philosophical argument that a freer market is worth the trade-off. But you often hear this folk wisdom in Washington for a reason: It's harder to vote to take a benefit away from people than it is to give them one.

That's the obstacle the AHCA has to clear that Obamacare never did.

Chart of the Day


The geography of America's remaining uninsured. New data from the Centers for Disease Control and Prevention shows that the country's chronically uninsured are increasingly concentrated in the South, where many states have refused to expand Medicaid under Obamacare. Read more from the CDC here.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day:

  • "Ryan moves to ax lawmaker exemption in Obamacare repeal bill": “House GOP leaders are moving quickly behind the scenes to iron out a wrinkle in their latest Obamacare repeal legislation: a controversial provision that preserves Obamacare coverage protections for members of Congress and their staffs while allowing states to opt out of them.” —Rachael Bade and John Bresnahan, Politico
  • "Molina will exit exchanges if ACA payments aren't made": “Dr. J. Mario Molina, CEO of health insurer Molina Healthcare, sent a warning Thursday to Republicans in Congress and the Trump administration: If the Affordable Care Act cost-sharing reduction subsidies are not funded, Molina will ‘withdraw from the marketplace immediately.’ Molina's letter — addressed to Paul Ryan, Mitch McConnell, Nancy Pelosi and Chuck Schumer — said the company has priced the subsidies into next year's premiums and that they are ‘not a bailout or windfall.’” —Bob Herman, Axios
  • "Work requirements for Florida Medicaid recipients move forward in House": “Some low-income people who rely on Medicaid may have to meet new work requirements to keep their healthcare under legislation passed by the Florida House on Wednesday. Medicaid recipients who are able to work would have to prove to the state that they are working, actively seeking work or enrolled in a job-training program.” —Michael Auslen, Miami Herald

Analysis and longer reads:

  • "Value-Based Pricing For Pharmaceuticals In The Trump Administration": “Allowing Medicare to negotiate drug prices is one popular possibility; outright price controls are also under discussion. But with Republicans in control of both Congress and the White House, neither appears to be on the policy agenda. But one market-friendly alternative, ‘value-based pricing,’ may hold more promise.” —Rachel Sachs, Nicholas Bagley, and Darius Lakdawalla, Health Affairs Blog

"Health Policy’s Gordian Knot: Rethinking Cost Control": “Medical spending has resumed its long-term rise. After several years of deceptive stability in the last, deep recession’s wake, health spending rose by 3.7 percentage points more than general inflation in 2014, then by 5.8 percentage points more in 2015, to a 17.8 percent share of the US economy. Not only does this spending rise threaten the United States’ fiscal stability and capacity to address other needs; it is undermining the promise of health care for all.” —Gregg Bloche, Neel Sukhatme, and John L. Marshall, Health Affairs Blog

Sign up for the newsletter Sign up for Vox Recommends

Get curated picks of the best Vox journalism to read, watch, and listen to every week, from our editors.