Republicans can still succeed in destroying Obamacare

In recent days, a procession of GOP senators has paraded forth and declared in somber tones that the effort to repeal and replace Obamacare may be failing. Mitch McConnell, the GOP Senate leader from Kentucky, recently said he didn't see a path yet. Or, as GOP Sen. Lindsey O. Graham put it: "I just don't think we can put it together among ourselves."

But some Democratic Senate aides don't buy it. With a Senate vote now expected this month, they are bracing for several scenarios in which Republicans produce surprise tactics at the last minute that enable them to pass something. This would then get them through to the next stage – negotiations between the House and Senate – which would have the virtue of increasing the pressure on reluctant holdouts to pass the final bill, pulling the trigger and destroying the Affordable Care Act for good.

One such scenario involves writing a bill that defers dealing with some of the tough details just to get through to conference committee, where the Senate and House bills would be reconciled, a Democratic aide tells me. In this rendering, the aide says, McConnell "puts together something very limited to go to conference, putting off hard decisions until the final bill is written with the White House at the table."

Right now, Republicans face several obstacles. One is that some senators from states that have expanded Medicaid – there are 20 GOP senators from such states – are balking at the Medicaid cuts in the House bill. The measure that passed the House would cut more than $800 billion from Medicaid and restructure the program to transfer more control to the states (which means more cuts and more draconian conditions, and fewer covered) and do away with the ACA's Medicaid expansion. Senate Republicans are mulling a version that would roll back the Medicaid expansion a bit more slowly. This would create "a smoother glide path," claims Sen. John Barrasso, RWyo., in a bit of very smooth rhetoric that glides over the likelihood that the Senate version will still cut Medicaid for untold numbers of poor people.

Senate Republicans are also mulling subsidies that are somewhat more generous than the House bill (which overall would leave 23 million additional people uninsured, according to the Congressional Budget Office). And Axios reports that the Senate version might also soften the House bill by allowing states to waive the requirement that insurers cover "essential health benefits" while not allowing them to waive the prohibition on jacking up premiums for people with preexisting conditions, a provision in the House bill. But we simply don't know what the Senate bill will look like just yet.

Democratic aides are preparing for several tactics that Senate Republicans could employ to get moderates to support the bill. One is to create a "placeholder" or "shell" bill that does not work out too many details of the Medicaid cuts, allowing moderates to say they will protect Medicaid in conference negotiations, a senior Democratic aide tells me. "If they try this route, Democrats will absolutely hold every single Republican senator accountable for that vote," the aide says. "Republicans will be voting to dismantle our health-care system, and we'll make sure people understand that."

"Republicans are dead-set on getting to 50 votes so they can jam some version of Trumpcare through the Senate," Sen. Patty Murray, D-Wash., told me in an emailed statement. "So Democrats are looking at every possible scenario."

"Conceptually, they could leave unaddressed many of the details of the Medicaid cuts and work them out in conference," Sarah Binder, a congressional expert at George Washington University, tells me, while cautioning that this is speculative. "They can deal with a vague Senate provision and a detailed House provision in conference."

A second scenario might be to insert language into the bill that obfuscates its true legislative impact. "They could put language in the bill that would make a political statement about, say, protecting those with preexisting conditions, even as the policy consequences would be different," Binder says. Or, Binder suggests, it could include weaselly language on Medicaid cuts, such as: "Nothing in this bill should be construed to limit people entitled under the law to Medicaid coverage."

Of course, all of this is a reminder of a basic fact about this whole debate: The GOP's massively regressive designs on the ACA – which at bottom constitute rolling back health coverage for untold millions of people to finance a huge tax cut for the rich – are deeply unpopular. By exposing those true designs to the public, this debate has succeeded in making Obamacare more popular and has underscored public opposition to rolling back the historic coverage expansion it has achieved, despite all its real flaws and need for improvement.

And so, the CBO could do serious damage to any such GOP tactic by releasing a score of the Senate bill (when it is done) that shines a harsh light on what the bill would actually do. But Andy Slavitt, a former acting administrator for the Centers for Medicare and Medicaid Services in the Obama administration, unleashed a tweet storm pointing out that, by keeping their bill behind closed doors for as long as possible, Republicans might limit the time that the public and the press have to absorb the CBO score's implications before holding a vote.