Trump likely to play a lead­ing role in ACA re­place­ment ef­forts

The Washington Post Sunday - - POLITICS & THE NATION - BY DAVID WEIGEL, MIKE DEBONIS AND KELSEY SNELL david.weigel@wash­post.com mike.debonis@wash­post.com kelsey.snell@wash­post.com

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.”

MELINA MARA/THE WASH­ING­TON POST

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.

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