Repub­li­cans caved to con­ser­va­tives on health care, and now it’s haunt­ing them

The Washington Post Sunday - - POLITICS & THE NATION - @PKCapi­tol PAUL KANE paul.kane@wash­post.com

Repub­li­cans weren’t sup­posed to drive them­selves into this par­tic­u­lar box canyon. “We want to make sure that peo­ple with pre­ex­ist­ing con­di­tions con­tinue to get cov­ered,” Rep. Greg Walden (ROre.) said in a Jan­uary 2017 in­ter­view with CNN dur­ing the GOP is­sues re­treat in Philadel­phia that charted the agenda.

As chair­man of the House En­ergy and Com­merce Com­mit­tee, Walden was charged with writ­ing leg­is­la­tion in­tended to fi­nally re­peal Oba­macare. Walden, com­ing off a four-year stint as the top cam­paign strate­gist, knew one thing for cer­tain: Do not mess with the Af­ford­able Care Act’s pro­vi­sion for­bid­ding in­sur­ers from deny­ing cov­er­age be­cause of pre­ex­ist­ing med­i­cal con­di­tions such as cancer, asthma or di­a­betes.

So the first draft of the Amer­i­can Health Care Act left that very pop­u­lar pro­vi­sion in­tact and House Speaker Paul D. Ryan (R-Wis.) ad­vanced the bill to the floor in late March — only to run into a con­ser­va­tive re­bel­lion led by Rep. Mark Mead­ows (R-N.C.) and the House Freedom Cau­cus.

Af­ter a hasty meet­ing with Pres­i­dent Trump, Ryan pulled the bill from the floor.

Look­ing back with 20/20 po­lit­i­cal hind­sight, those next six weeks be­came the most crit­i­cal pe­riod of this midterm elec­tion sea­son. Ryan and Trump caved to the con­ser­va­tives and in­serted lan­guage in the bill that weak­ened the pre­ex­ist­ing con­di­tion rules — al­low­ing states to let in­sur­ers charge some peo­ple more — and thereby handed Democrats their most lethal po­lit­i­cal weapon against Repub­li­cans.

Democrats are now slightly fa­vored to win the House in Tues­day’s midterm elec­tions, an out­come that might have hap­pened even if Repub­li­cans had never added the pro­vi­sion to change the 2010 law’s core pro­tec­tion. The orig­i­nal health­care pro­posal al­ready faced a hos­tile au­di­ence with es­ti­mates show­ing more than 20 mil­lion fewer peo­ple would have in­sur­ance over the next decade.

Giv­ing into the con­ser­va­tive de­mands on pre­ex­ist­ing con­di­tions pro­vided the fi­nal votes to ap­prove a new ver­sion of the re­peal bill in early May, prompt­ing singing chants of “Na Na Hey Hey Kiss Him Good­bye” from Democrats.

Now, more than any other is­sue, pre­ex­ist­ing con­di­tions have dom­i­nated the air­waves in House and Se­nate races. Al­most 55 per­cent of all Demo­cratic ads from mid-Septem­ber to mid-Oc­to­ber men­tion health care, broadly speak­ing, ac­cord­ing to a study by the Wes­leyan Me­dia Project, and al­most ev­ery sin­gle one men­tions the threat to pre­ex­ist­ing con­di­tions.

Repub­li­cans are just be­gin­ning the re­crim­i­na­tions over that de­ci­sion 18 months ago, par­tic­u­larly among those now fac­ing the bar­rage of ads fo­cus­ing on that move.

“The mem­bers who were call­ing for those changes re­ally don’t care. And they’re very self­ish, they al­ways have been,” Rep. Car­los Curbelo (R-Fla.), who voted for the bill, said in an in­ter­view last week out­side his cam­paign head­quar­ters in Mi­ami.

Mead­ows, through a spokesman, de­clined to com­ment about the in­ter­nal GOP de­bate in early 2017.

The fall­out blasted far and wide, well be­yond the few dozen mem­bers of the moder­ate Tues­day Group cau­cus who had been sup­port­ive of Walden’s orig­i­nal stance. Prom­i­nent cen­trist Reps. Tom MacArthur (R-N.J.) and Fred Up­ton (RMich.), who ne­go­ti­ated the fi­nal de­tails of the lan­guage on pre­ex­ist­ing con­di­tions, now find them­selves in the fight of their po­lit­i­cal lives, un­der con­stant at­tack for their work with Mead­ows.

Mead­ows’s own Freedom Cau­cus col­leagues, par­tic­u­larly Reps. Dave Brat (R-Va.) and Scott Perry (R-Pa.), find them­selves in toss-up races and on the de­fen­sive about that May 2017 vote.

Per­haps worst of all, the Se­nate choked on its own ACA re­peal bill and Oba­macare is still the law of the land. House Repub­li­cans walked a po­lit­i­cal plank that got sawed off be­hind them, lead­ing to false hope that the is­sue would fade away by Tues­day’s elec­tion.

A group of Repub­li­can state at­tor­neys gen­eral filed a law­suit ques­tion­ing the health law’s con­sti­tu­tion­al­ity and the Trump ad­min­is­tra­tion sided with them, keep­ing the is­sue front and cen­ter.

Repub­li­cans now sound ex­as­per­ated about the is­sue. “It was only a two-page amend­ment,” MacArthur said on a recent tele­phone town hall with se­niors in his cen­tral New Jersey dis­trict.

Po­lit­i­cally, it was so much more than that. “The orig­i­nal sin of the Repub­li­can Party was that health-care vote, and noth­ing was more sin­ful than gut­ting that pre­ex­ist­ing con­di­tion guar­an­tee,” said Jesse Fer­gu­son, a Demo­cratic strate­gist who con­sults for lib­eral groups run­ning health-care ads.

An Au­gust sur­vey, by Kaiser Health, found 75 per­cent of Amer­i­cans sup­port­ing the ACA’s guar­an­tee for pre­ex­ist­ing con­di­tions.

But, in late March 2017, the Mead­ows wing ar­gued elim­i­nat­ing man­dates on in­sur­ance com­pa­nies would lead to lower pre­mi­ums for con­sumers.

Af­ter the ini­tial fail­ure, the North Carolinian sat down with MacArthur and came up with a com­pli­cated process that al­lowed states to grant waivers to in­sur­ance com­pa­nies so they could opt out of guar­an­tees for pre­ex­ist­ing con­di­tions and some es­sen­tial health ben­e­fits.

Some Repub­li­cans be­lieved this was such a high hur­dle that few states would have ac­tu­ally tried to get those waivers. Oth­ers be­lieved the im­pact would be slight — very few ac­tu­ally de­nied cov­er­age be­cause of pre­ex­ist­ing con­di­tions and lim­ited im­pact on pre­mi­ums.

If that were the case, some Repub­li­cans pri­vately won­dered, why go through with such an ef­fort? All they did was open them­selves up to Demo­cratic lines of at­tack.

By late April 2017, then-Rep. Char­lie Dent (R-Pa.), a lead­ing moder­ate, ac­cused Mead­ows of just go­ing through “an ex­er­cise in blame shift­ing,” so that if the re­peal ef­fort died again it would be the Tues­day Group that sunk it.

Ad­vis­ers to the con­ser­va­tives bris­tle at the no­tion that they forced any­one to vote for any­thing, that each law­maker can ex­er­cise his or her own vote.

Ul­ti­mately, most Repub­li­cans de­cided vot­ing for the new re­peal bill was more im­por­tant than the risk as­so­ci­ated with deny­ing in­sur­ance guar­an­tees.

“I think hon­esty and sin­cer­ity are the most im­por­tant char­ac­ter­is­tics or qual­i­ties for any­one in pub­lic of­fice,” Curbelo said. “And I made a com­mit­ment when I first ran, in 2013, that I would try to re­peal the ACA and re­place it with some­thing bet­ter.”

In Fe­bru­ary 2017, Walden in­tro­duced a stand-alone bill to pro­tect guar­an­tees for pre­ex­ist­ing con­di­tions. That leg­is­la­tion never ad­vanced be­yond a sub­com­mit­tee, but its 81 co-spon­sors reads like a Who’s Who of en­dan­gered House Repub­li­cans try­ing to prove their bona fides on the is­sue.

The fi­nal GOP law­mak­ers signed on in the late sum­mer as the po­lit­i­cal cli­mate be­came more dire, in­clud­ing one fa­mil­iar name: MacArthur.

AARON P. BERN­STEIN/GETTY IM­AGES

Pro­test­ers out­side the Capi­tol build­ing in June. Health care has be­come a dom­i­nant is­sue on the cam­paign trail, and Repub­li­can ef­forts to un­der­mine the pre­ex­ist­ing con­di­tions guar­an­tee in the Af­ford­able Care Act has given Democrats a lethal weapon against them.

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