When the White House says the administration is "all in," this is what they mean. The president is warning conservative critics of the new GOP healthcare bill that if Republicans face-plant on repeal and replace, voters will revolt next fall. He's also meeting with various groups in an effort to tamp down opposition through a combination of blunt force, cajoling, and perhaps some Trumpian deal-making. Stay tuned. Yesterday we reviewed the attributes and flaws of the Trump-Ryan healthcare bill, committee mark-ups of which begin today. As we noted, the proposal has unsurprisingly garnered near-universal condemnation from the Left, but is also under attack from significant elements of the Right. Senior Republicans caution that focusing on the loudest negative voices within the party and conservative movement distorts the bigger picture: That most House Republicans have buy-in on the bill, as they've been looped-in on the drafting process for months. But relatively strong support among the rank-and-file won't necessarily translate to 218 votes, which is why the debate over finalizing legislative language may prove crucial. Amid searing criticism from some conservative groups, President Trump and Speaker Ryan's plan received a powerful endorsement this morning in a Wall Street Journal editorial calling the legislation "the most consequential GOP social-policy reform since the welfare overhaul of 1996:"
The American Health Care Act would be the most consequential GOP social-policy reform since the welfare overhaul of 1996. Not only does the bill repair the failures of the Affordable Care Act, it starts to correct many of the government-created dysfunctions that have bedeviled U.S. health care for decades. Opening this critical legislative campaign is a test of how well Republicans can manage political and economic reality. The House bill is a center-right compromise that works off a status quo that has accumulated for years, and its architects know they can’t design a health-care system de novo. The bill has flaws that come from accommodating what the votes in Congress will allow. Still, if this passes, it will be a major achievement, and real progress. Though the individual insurance market dominates the debate, the House’s Medicaid reform might be more important. This safety-net program originally meant for poor women, children and the disabled has morphed into general insurance for working-age, able-bodied adults above the poverty level, despite its low-quality care and price controls. The House would convert Medicaid’s funding formula from an open-ended entitlement into block grants to states. The amount would be determined by per capita enrollment and grow with medical inflation. States would thus have a reason to set priorities and retarget Medicaid on the truly needy.
President Trump said Tuesday he is “proud” to support the House bill and hopes it passes quickly. His leadership will be critical, especially as strife grows on the right about the allegedly insufficient conservative purity of the House plan. These critics say they want outright repeal first, and then maybe Congress can pass a replacement someday. But Mr. Trump ran on “repeal and replace” and House Republicans united around the “Better Way” plan. They promised real solutions to ObamaCare’s problems. Repeal-only can’t pass the Senate in any case, because Senate Republicans—with good reason—don’t want to accelerate ObamaCare’s collapse or throw millions off the Medicaid rolls. Voters tend to punish parties that disrupt their insurance. Just ask Democrats. In other words, the House bill is the only heath-care show in town. If conservatives join Democrats to defeat the measure, the result will be to preserve ObamaCare as is—and probably torpedo the rest of the GOP agenda including tax reform. Good luck running for re-election in 2018 with a record of failure.
Read the whole thing. It concludes by urging some changes through the amendment process, then final passage, arguing that outcome would represent "a major down payment on a brighter health-care future. Republicans have a limited window for repeal and replace, and this is a once-in-a-generation opportunity. Democrats understand this, even if some conservatives don’t." On the other end of this tug-of-war, National Review's editorial casts GOPCare as a "disappointing start" to the repeal-and-replace legislative saga, even while acknowledging strong points in the plan. The conservative magazine's editors argue that working within he confines of the budget reconciliation process has tied Republicans' hands, forcing them to offer an incomplete bill. "It...seems to us that Republicans would be better off rallying behind a bill in which they really believe, even if Democrats kill it with a filibuster, than trying and failing to enact a bill that they support only tepidly," the write. I disagree. The goal now is results, not symbolism. Unlike previous repeal votes with President Obama waiting down the road with a veto pen, the GOP has now a real chance to roll back big elements of this failing law, and replace them with better (if imperfect) solutions. Why waste time crafting an ideal, comprehensive bill that will fail under a Democratic filibuster when the reconciliation tool creates the 51-vote threshold that Democrats used to ram through the finishing touches of their scheme in 2010? This critique, which we touched on yesterday, does require a serious response, however:
[The bill] eliminates Obamacare’s fines on people who go without insurance, but in their place creates a new surcharge for people who let their insurance lapse and then try to purchase a new policy. The goal is to keep healthy people from leaving the insurance rolls and thus destabilizing insurance markets. The surcharge is a heavy-handed instrument: Insurers would be obligated to impose it regardless of their preferences. Yet the surcharge might not achieve its goal. A lot of healthy people might well decide to go without insurance and run the risk of paying a surcharge if they get sick later. The surcharge even undermines its own goal, since it would discourage healthy people who had already left the insurance rolls from getting back on them.
Others have made the same point, expressing skepticism that this mechanism would succeed in righting the sinking USS Adverse Selection. The Journal's editors took a stab at that issue in their piece quoted above: "Critics claim this change will tank the insurance markets, but the GOP bet is that if insurers are allowed to sell lower-cost products that people want to buy, people will buy them without a mandate. By loosening rules that standardize coverage and extending financial help to consumers, the goal is to stand up a more vibrant market with more choices than ObamaCare permits." But is there any data that could inspire confidence that this "GOP bet" is a smart one? I'll leave you with a key House committee chairman defending the bill on Hugh Hewitt's show this morning, and a piece by reporter David Drucker about how Republicans risk preserving Obamacare by fighting each other:
HEWITT: Chairman, it looks to me like the American Health Care Act is the best possible repeal and replace bill that can make it through the Senate to the President’s desk, and that therefore, critics of it have to deal with the fact this is the best you can get. Is that the central selling point?
WALDEN: You know, it’s, I think that’s part of it, and the second part of it when we get it to President Trump’s desk, it will amount to the biggest entitlement reform, the biggest transfer of power back to states, at least since Medicaid was created, but also since President Clinton signed welfare reform. This is big entitlement reform, Hugh. It’s really important. We put a lot of work into this. And I think it will transform health care in America, but more, as importantly, it will also begin to bend down the cost curve and restore innovation and opportunity to states, but put Medicaid on a budget. All those are important Republican conservative principles many of us have been fighting for, for years and years and years...
HEWITT: ...Does the Freedom Caucus understand, the narrow gate is in the Senate? And if they don’t satisfy 51 Senators, there’s no repeal and replace. Do they get that?
WALDEN: I hope they get that. I’m going to talk at our Republican conference again this morning on that. I hope your listeners will tell them that. It is really, really difficult and important. And if we, you know, part of what we’re getting criticized for is what’s not in this bill. And Hugh, you understand reconciliation...There are a lot of things that we will do going forward in the next bucket that we are prohibited from putting in this bill because of the rules of the Senate on reconciliation. So we could load this thing up, but then you’ve got to get 60 votes in the Senate. If you can get 60 votes in the Senate, I’m all for doing more. But you know, we have to operate under the rules of the Senate here because of reconciliation. The parliamentarian makes that decision...And if we lose that opportunity, then we go from 51 votes to 60, and you know how hard that is. I want to get as much reform as I can here.
The "next bucket" to which Walden refers are the next two steps of this process after the reconciliation bill: HHS regulations from Sec. Price (Obamacare put a lot of power in the hands of the HHS secretary, which may come back to bite its designers), and regular-order policy proposals that cannot be shoehorned into a filibuster-avoiding reconciliation bill under the rules. Also, in case you missed Leah's post earlier, here's Charles Krauthammer arguing that yes, GOPCare can be fairly portrayed as 'Obamacare Lite,' but its basic outlines are the only politically-viable shot at undoing the worst of Obamacare's damage. Political realities and historical lessons aren't secondary concerns; they're central to the debate: