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Trump is in dealmaking mode to pass health care — and he might just get the votes

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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.

House leaders and President Trump are pulling out all the stops to get the American Health Care Act passed in the House after several false starts. They’re down to offering individual lawmakers very specific deals to earn their vote.

Speaker Paul Ryan and the White House are scrambling as of Wednesday morning. Some lawmakers are heading to the White House for a sit-down with the president. Top administration officials are signaling that the votes are nearly there and they expect a House vote soon. Ryan has cautioned that he won’t set a timetable on the vote, which suggests leadership doesn’t quite yet have the support it needs.

The big “deal” was a major amendment to the bill negotiated by the conservative House Freedom Caucus and one centrist lawmaker. That provision would allow states to opt out of some of Obamacare’s insurance rules, so long as they met certain criteria, such as setting up high-risk pools. That brought most of the 30-odd members of the Freedom Caucus to the “yes” column last week, a big breakthrough for House leaders and Trump.

But a few conservatives still held out, and moderates have balked at the bill’s Medicaid cuts and changes to Obamacare’s protections for people with preexisting medical conditions. With the Freedom Caucus largely on board, attention has turned to winning over lawmakers one by one.

Some of these agreements are only tangentially related to the health care bill. Others would actually change the legislation. Here’s what we know.

Fred Upton and Billy Long got more money for sick people

The defections this week of Upton and Long — two reliable leadership allies (Upton is also an experienced health care legislator) — were a bad omen for the amended version of AHCA. So they have become the focal point of the latest whipping efforts, and both are meeting with Trump on Wednesday.

Upton will reportedly propose $8 billion in additional funding to help people with medical conditions afford insurance, designed to win his support along with that of Long and (perhaps) other wavering moderates.

The specifics of the funding proposal are not yet clear, but it appears designed to address one potential hole in the AHCA waivers: In states with waivers, people cannot be charged more for their insurance because of their health, as long as they maintained health coverage.

But if people have a gap in their coverage, they could be charged more for insurance. The Upton amendment would be intended to help those people, it seems. Legislative text has not yet been made available.

“The proposed amendment would provide $8 billion over five years to reduce premiums and other out-of-pocket costs for individuals with preexisting conditions, who have a gap in coverage, in states that receive waivers,” a House aide told me.

Upton and Long said after their meeting with Trump that they would now support the bill.

Paul Gosar got a vote on his own health care bill

Gosar was one of the staunch conservatives holding out against AHCA even after the Freedom Caucus as a whole endorsed the bill. But he told reporters on Tuesday that he would vote for the legislation after securing a promise that a separate bill of his, which already passed the House, would get a vote in the Senate.

“I got assurances that my competitive health care bill, which passed here in the House ... gets a full vote in the Senate,” Gosar told reporters. He said he had received those assurances from the White House, Vice President Mike Pence’s office, and Ryan’s office.

Gosar said the bill is the Competitive Health Insurance Reform Act of 2017, which passed the House with 416 votes in March. The legislation would subject the health insurance industry to antitrust laws that it is currently exempted from.

“Nobody’s going to vote against that,” Gosar said.

Lou Barletta got a hearing on an immigration health care bill

Barletta, another holdout and an immigration hardliner, said that he would now support the bill after Trump and top House Republicans promised to advance his bill designed to stop undocumented immigrants from receiving government assistance to purchase health insurance through AHCA.

From Talking Points Memo:

Rep. Lou Barletta (R-PA), who previously opposed the American Health Care Act out of fear undocumented immigrants could somehow receive tax credits to purchase health care, said that his vote has been won over by promises from President Trump and GOP leaders that they will advance a separate bill this month that “will require that a person’s Social Security number is verified before we give them a tax credit.”

“I talked to the President at length last night and he agreed 100 percent that he wants it fixed as well,” Barletta told reporters Tuesday. “So my issue is going to be taken care of. I’ve got a letter that puts in writing, from Treasury and Homeland Security.”

“It’s really an excellent piece of legislation,” House Ways and Means Chair Kevin Brady, who confirmed the deal, told reporters. “We haven’t set a date for a markup yet but I anticipate it coming before the end of the month.”

New York lawmakers got the “Buffalo Buyout”

This policy isn’t new to the latest negotiations, but it’s still worth noting. The AHCA includes a provision aimed specifically at New York’s Medicaid program, a provision that initially helped earn the support of lawmakers like Rep. John Faso who represent rural areas in the state.

New York is unusual in that its county governments are required to pay a share of the state’s Medicaid expenses. The provision in the AHCA is designed to address that issue, at least for rural counties. Here’s what it would do, as Jeff Stein explained last month:

Politicians in rural New York have long complained that their state’s Medicaid expansion inflicts a heavy tax burden on local counties, driving up local property taxes. The Huffington Post reports that counties are forced to pay about $7 billion of the state’s $27 billion Medicaid liability.

Members of both parties in upstate New York have long criticized Gov. Andrew Cuomo (D-NY) for pushing this “unfunded mandate” onto their tax rolls. They say that the state should instead pay for the Medicaid expansion, which can eat up as much as 70 percent of the local property tax revenue in some counties.

As a result, Rep. Chris Collins (R-NY) has led the charge during the debate of AHCA to force the state to pay for the expansion entirely, by changing the rules surrounding Medicaid.