Trump likely to play a leading role in ACA replacement efforts
The internal Republican battle over replacing the Affordable Care Act has become the GOP’s first chance to break the House Freedom Caucus, the bloc of more than two dozen conservative lawmakers who have frustrated leadership for two years.
And President Trump is likely to play a leading role.
Trump’s intervention in the debate over an unpopular ACA revision put forth by House Speaker Paul D. Ryan (R-Wis.) has left both the party’s leadership and its rebels convinced that they have an ally in the White House. The president has told conservatives he is open to negotiating changes to the bill, but after Trump met with GOP leaders Friday, his press secretary, Sean Spicer, said the opposite.
Doctors, hospitals, insurers and seniors have all weighed in against the Ryan plan, framing the broader debate over Obamacare’s fate primarily on how many Americans could lose coverage. Republicans, however, are selling their revisions as phase one in a three-phase repeal, so they are less focused on whether the bill could work. For them, the question is whether the GOP can govern without a right-wing litmus test blocking the way.
In news conferences, interviews and PowerPoint presentations, Ryan’s sales pitch has been directed not at industry opponents, but at the Freedom Caucus. Nor has he focused much on the substance of the proposal. On Thursday, he offered his conservative colleagues a “binary choice” between partial repeal of the ACA or total failure. On Friday, he suggested that some were simply being obstinate.
“This reflects a Republican consensus, and that’s the point. It’s a consensus bill,” Ryan told conservative radio host Hugh Hewitt. “We’re going through the growing pains of being an opposition party with Barack Obama to actually being a governing party with a Republican President Donald Trump. And that means we have to reach consensus on Republican priorities and principles. This reflects that.”
Members of the caucus, which has never revealed who belongs but includes at least 30 Republicans, have relished the attention — the most they’ve received since playing a key role in forcing out former speaker John A. Boehner in 2015. They’ve won praise from conservative media. They’ve gotten face time with the president and vice president of the United States.
They’ve surmised that the American Health Care Act, as Ryan’s proposal to revise the ACA is called, cannot pass without their votes. And they say they think that the White House is working around Ryan to meet at least some of their demands. The result, as they see it, is a speaker talking tough while committee chairs listen to the caucus.
At the same time, there are few signs that the conservatives’ demands will actually be met. Ryan has made clear that revisions to please the Freedom Caucus would make the proposal less palatable to moderates — and probably doom it in the Senate. At least some members of the Freedom Caucus appear to be considering supporting the proposal anyway.
“What we hear from the White House is, this is a work in progress,” said Rep. Mark Sanford (R-S.C.), the sponsor of Freedom Caucus-backed alternative legislation. “[Office of Management and Budget Director] Mick Mulvaney came here and talked to the Freedom Caucus two nights ago and he said this is a work in progress and we’re going to be open to amendments that you have to offer. Then we hear from leadership take it or leave it.”
The question is whether the caucus is being given a seat at the table — or being snowed.
“There hasn’t been the old days of let’s do a rah-rah and try to run everyone over,” said Rep. David Schweikert (R-Ariz.), a Freedom Caucus member who voted to advance the American Health Care Act in committee. “Remember, one of the reasons we became a group was because we wanted to be able to have a voice. We wanted to be able to have amendments. We wanted to have this.”
Conservatives see the elevation of former caucus member Mulvaney to the Office of Management and Budget as an advantage for them. Others see it as a way to fracture the group by giving the new president a broker they trust.
Similarly, conservatives say they see the past week’s huddles with Trump and his aides — more, including a get-together at the White House bowling alley, are coming — as evidence that the administration is working with them. Others see it as a classic instance of “good cop” salesmanship.
“President Trump is fully in the game, but he’s doing velvet glove,” Hewitt said in his interview with Ryan. “It’s pizza and bowling.”
Trump is an X Factor hovering over all of it. His popularity in virtually all of the Freedom Caucus members’ districts gives him enormous influence over the deliberations. If Trump tells the country that the Ryan plan is the way to go, conservative House members could think twice about saying otherwise.
“Will the iron fist come out?” Hewitt asked. “And will he put people up to run in primaries if they obstruct what is, I think, a moment-killing obstruction at this point? We’ve got to get this, or the rest doesn’t follow.”
It’s worth noting that the 2016 elections did not go as well for the Freedom Caucus as its members had hoped. Their public membership was reduced after several lost primaries or simply retired. And overall, the GOP’s six-seat loss was less than many caucus members expected, causing the counterintuitive result of limiting the caucus’s influence and ability to block bills. Republicans who say they think that the caucus will fracture on the AHCA point out that only eight or nine of them need to come over to pass the bill, assuming no other defections.
The president endorsed the AHCA, giving many the impression he favored it as is. Then, he concluded meetings with a group of grass-roots conservatives seemingly offering a concession, by suggesting that he is open to moving up the end of the ACA’s Medicaid expansion from 2020 to 2018. Then, on Friday, Spicer said negotiations are off the table.
All of it preserves uncertainty about what actually will happen — and who will get what they want.
“When he gets information from everybody, before the final decision is made, somebody might say, ‘Well, I had a great conversation with him,’ ” said Rep. Mark Meadows (R-N.C.), the chairman of the Freedom Caucus. “Then he’ll go and go in another direction and have another great conversation. That’s how business people make decisions.”
In many ways, the debate resembles one that has bedeviled Democrats since the passage of the ACA, and especially since its implementation began in 2013. Progressives favored several plans that would have essentially expanded Medicaid and Medicare, bringing tens of millions of Americans into a single-payer system.
That idea largely lost out to a combination of insurance exchanges and tax subsidies, which provided Republicans with years of horror stories about costly premiums and disrupted care. On the left, especially among those who supported the presidential campaign of Sen. Bernie Sanders (I-Vt.), it’s taken for granted that Democrats would have been in a stronger position had they endorsed the bolder plan.
The more resolute Freedom Caucus members, who largely represent safe seats, argue that voters will punish them if the ACA is not obliterated.
The AHCA keeps the cuts to Medicare spending that Republicans made infamous in campaign ads. It introduces new, refundable tax credits, promises lower premiums, extends a Medicaid expansion and cuts taxes for wealthier Americans — with no pretense of paying for any of it.
On Tuesday morning, House Ways and Means Committee Chairman Kevin Brady (R-Tex.) told reporters that the ACA had been “written in the dark of night and rushed through Congress.” Days later, his committee voted out the AHCA at 4:30 a.m. With each development, Freedom Caucus members see evidence that they, and not the party leadership, are doing what voters had asked of them.
“I might be the last person trying to prevent the Republican Party from being responsible for the largest welfare program in our history,” said Rep. Mo Brooks (R-Ala.). “The people in my district get it. They understand the risk of a debilitating insolvency. They understand that we’re looking at a $600 billion deficit this year. They understand that we’re blowing through the $20 trillion debt mark. They understand that within six years, we’re going to embark on a trillion dollar a year deficits indefinitely until such time as we collapse.”
That may change. The American Action Network, a 501(c)(4) that’s already spent $8 million on ads supporting the Republican majority in the health-care fight, went on the air this past week with commercials urging Freedom Caucus members to “support President Trump” and back the AHCA.
Some conservatives appear to understand the potential power of such messaging.
“My sense is that the president doesn’t care about the particular policy,” said Rep. Justin Amash (R-Mich.). “He cares about fulfilling a campaign promise to repeal and replace. Anything that’s presented as ‘repeal and replace,’ and makes it through Congress, he’ll be happy to sign.”
House Speaker Paul D. Ryan (R-Wis.) talks about the replacement bill for the Affordable Care Act. His pitch for the American Health Care Act has been directed at the Freedom Caucus.