Health bill faces tough hurdles
House GOP’s measure now moves to skeptical Senate
WASHINGTON — The Rose Garden celebration that President Trump held with House Republicans following their passage of a bill to repeal of the Affordable Care Act looked like a bill signing, except for one missing detail: the pens.
The health care bill still must get through the Senate, and as one Republican strategist predicted Friday, it won’t be easy.
Some form of legislation that follows the broad contours of the House bill “is going to get through the Senate,” said Republican strategist Ford O’Connell. To achieve that, he said, will require maintaining extreme party discipline to unite the same conservative and mainstream GOP factions in the Senate that caused the Republicans’ effort to repeal the Affordable Care Act to implode in March in the House.
Republicans “know they’re going to own this, one way or the other,” O’Connell said. “They want to make it as good as possible, but they know that if nothing else they can ... run out there and say it is less bad than what you guys were facing,” under the current health law.
The hurdles are enormous, starting with deadlines. Republicans must produce a bill by September to use a parliamentary procedure, set to
expire, that permits budget legislation to pass by a simple Senate majority. Republicans hold a narrow 52-48 majority and must use this procedure to have any hope of passing a repeal bill that Democrats adamantly oppose.
With Republicans in control of both houses of Congress and the White House, no one imagined it would take the House more than four months to pass a repeal bill, and the Senate moves much more slowly.
A bigger problem is the substance of the GOP legislation itself. Senate Republicans have been conspicuously cool to the House version, known as the American Health Care Act, extending anywhere from faint praise for the effort to bald vows of a complete rewrite.
“We’re writing a Senate bill and not passing the House bill,” said Sen. Lamar Alexander, R-Tenn., and a key committee chairman on health legislation.
Senate Majority Leader Mitch McConnell, R-Ky., called the bill “an important step.”
The bill also faces strong opposition from such powerful groups as the American Medical Association and AARP.
“There’s very little in this bill that lends itself to a populist message,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health care think tank. “It reduces the number of people covered, potentially takes away protections for people with pre-existing conditions, and increases out-of-pocket costs and premiums.
“So this is not a bill that’s easy to sell to the public, aside from the symbolism of repealing and replacing the Affordable Care Act.”
House Minority Leader Nancy Pelosi, D-San Francisco, a chief architect of the Affordable Care Act, pointed last week to one of the conundrums that Republicans face in trying to repeal the law. The Affordable Care Act, in fact, is modeled on a construct produced by the conservative Heritage Foundation that relies on insurers and market mechanisms to expand coverage.
As a consequence, analysts say, Republicans are finding it hard to make a law that already relies on market mechanisms even more market-oriented without gutting the parts that work to expand coverage. They have had to devise substitutes that don’t work as well or are just as unpopular. For example, they dropped the mandate that everyone buy insurance, but substituted a 30 percent surcharge on people who let their policies lapse.
Another hurdle that will loom especially large in the Senate is the Medicaid expansion, a chief tool the current law uses to expand insurance coverage. Conservatives loathe this element of the law, which they see as costly big government. The House bill slashes the Medicaid expansion by $880 billion.
But unlike the House, where most lawmakers are protected by gerrymandered districts that allow them to cater to hard-core partisans, senators represent whole states and a broader public. Several Republican senators, such as Rob Portman of Ohio, represent states that expanded Medicaid and could lose billions of dollars in federal aid under the House bill, forcing huge swaths of their constituents to lose medical coverage.
But conservative GOP senators such as Ted Cruz of Texas and Mike Lee of Utah represent states that did not expand Medicaid and strongly oppose
“There’s very little in this bill that lends itself to a populist message . ... So this is not a bill that’s easy to sell to the public, aside from the symbolism of repealing and replacing the Affordable Care Act.” Larry Levitt, Kaiser Family Foundation senior vice president
Medicaid expansion.
“The House was able to thread the needle, but there’s still the tension between moderates uncomfortable with pulling the rug out from people’s coverage and conservatives who are more focused on cutting federal spending and taxes,” Levitt said.
People with pre-existing conditions such as cancer or diabetes pose another hurdle. They constitute more than a quarter of the U.S. population, and many live in states that voted for Trump.
Trump himself promised that Republicans would not turn away sick people, and during House negotiations, Speaker Paul Ryan, R-Wis., ordered the lawmakers negotiating the bill to make sure people with pre-existing conditions would be covered.
“Obamacare created an entitlement whether we agree with it or not,” O’Connell said. “Republicans are scared to get rid of that entitlement, and that comes down to pre-existing conditions. That’s the one thing we look at over and over in polling that’s popular.”
Under current law, insurance companies are not permitted to deny coverage or charge higher premiums to people with medical conditions.
The House bill would let states opt out of this requirement and substitute federal subsidies to help pay for these expensive claims. But it also allows insurers to charge this group higher premiums, if a state establishes a “high-risk pool” or other mechanism where the government provides subsidies to insurers.
House leaders were able to pass their bill only after plumping up the money for these subsidies. But independent analysts said the subsidies remain woefully inadequate. Such pools have been tried in many states, but have never worked well because they are almost always underfunded. Sick people have been put on waiting lists or faced other restrictions to get into the pools.
Another big complication is Trump himself. The president often seems confused about health policy, and has infuriated lawmakers with sudden declarations and promises that are in direct conflict with their efforts.
On Thursday, just after celebrating passage of the House bill, Trump praised Australia’s government-run health care system in a meeting with Prime Minister Malcolm Turnbull.
After bashing the Affordable Care Act, Trump told Turnbull, “You have better health care than we do.”