Nothing will be so important for the success of the Trump administration – save perhaps a war with North Korea – as the passage of comprehensive healthcare legislation. The national rise of conservatives to political power since 2010 has been energized by the promise to repeal Obamacare. The Trump, Ryan, McConnell braintrust has determined that healthcare must come before tax reform and the transformational FY2018 budget. A significant part of the appeal of Trump is his reputation as a deal maker. Failure is not an option.

The setting:

– The American Healthcare Act which was introduced on March 6 and would be phased in through 2020, replaces the Obamacare subsidies with age-adjusted tax credits; stops the federally funded expansion of Medicaid after 2020; expands Health Saving Accounts; eliminates individual and corporate mandates; eliminates most Obamacare taxes; retains the “pre-existing conditions” and “age 26 parent policy” requirements; and provides more decision making to the states.

– The Congressional Budget Office – which missed by a wide margin in scoring Obamacare – estimates that the change would save $337 billion over 10 years, those uninsured would increase by 24 million by 2026 (about half due to opting out with the removal of the individual mandate), and long term rates would be about 10% lower.

– Public opinion has been shifting, with a slight majority now approving of Obamacare according to Pew Research. With some popular provisions retained, the Republican version has 46% approval versus 35% disapproval.

– Passage will require fewer than 21 net defections in the House and 2 net defections in the Senate. The plan is to limit content to what would qualify for the Reconciliation process which will require only 51 votes in the Senate.

Reasons for caution:

– It is not nearly enough to demonstrate that Obamacare is collapsing. The Democrats also have an alternative – single payer Medicare for all.

– There is a fundamental difference of opinion between the more ideologically conservative House Republicans who primarily want the federal government out of the game, and the more moderate Senate Republicans who are concerned about insurance for the poor.

– Back in the day of earmarks, legislative leaders were able to buy votes with dams and new hospital wings in the district or state. Now it is much more about ideology and pragmatic political leverage.

– Trump can generate enthusiasm with mass rallies, but the combination of #Resist, and a hostile media provides a drumbeat of opposition to anything.

Reasons for optimism:

– Republicans know that they have to do this.

– There are a lot of negotiable provisions: amount and structure of tax credits; structure and timing of Medicaid changes; the inclusion of a Planned Parenthood defunding requirement in the current draft; the amount of money for state-administered high risk pools. Representatives and Senators will be able to tell their constituents that they made a difference.

– The upcoming budget battle provides the legislative equivalent of earmarks. A vote for the American Healthcare Act can be traded for a changed provision on funding of foreign aid or medical research in the budget. Representatives and Senators will be able to tell their constituents that they made a difference.

– While there are numerous Representatives and Senators expressing concerns, Trump, Ryan, and McConnell have a number of sticks as well as carrots. Ryan seems to have control of his caucus – at least for this version of the Plan. McConnell has been occupied with Cabinet and Supreme Court appointments, but requires only a half dozen one-on-one conversations in his own somnolent style.

All said, this will provide good theater for the next month or two, but it would be shocking if the Republicans were not able to get it across the finish line by the end of April. If not, it would be clear evidence of an inability to govern.

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www.RightinSanFrancisco.com – 3/17/2017