President Trump campaigned on the pledge of creating a big, beautiful, “unbelievable” health care system to replace the Affordable Care Act, one that was less expensive, less confusing and more comprehensive than the current program.
Even before his inauguration in late January, the president-elect boasted to The Washington Post that he was on the cusp of a plan that would provide “insurance for everybody.” While he and his Republican allies in Congress would dismantle Obamacare with blinding speed, Trump promised confidently, he would preserve a few of the most popular features of the existing program.
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Trump was especially adamant about two of them: Allowing children to remain on their parents’ healthcare policies until they turned 26 and a ban on insurance companies jacking up the premiums of prospective policy holders with pre-existing medical conditions, like cancer or diabetes.
“I like those very much,” Trump told The Wall Street Journal last November.
Fast forward to today: The Trump-GOP drive to repeal and replace the Affordable Care Act is in shambles. For the second time in roughly a month, House Speaker Paul Ryan (R-WI) and his Republican lieutenants were forced to pull back from a vote on another iteration of their party’s ill-conceived effort because they couldn’t muster the votes necessary to pass it.
Instead, the House and Senate approved a one-week extension on this year’s spending authority to avert a government shutdown and adjourned for the weekend.
Administration officials had been pressing for a vote on a new health care plan ahead of Trump’s 100th day in office on Saturday, but it became painfully obvious by Thursday night that the leadership was nowhere close to the 216-vote majority needed. At least 21 House Republicans had come out against the latest bill and many others were still undecided. It would take just 22 Republican defections to bring down the measure.
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In truth, the White House and Ryan have all but lost control of the bargaining effort and instead have ceded most of the responsibility to several leaders of the arch-conservative Freedom Caucus and one moderate Republican from New Jersey, Rep. Tom MacArthur, who broke with many members of his moderate caucus, the Tuesday Group.
The prospects that the Freedom Caucus and MacArthur can ultimately craft a plan that is both credible and acceptable to a wide swath of Republicans in the House and Senate are slim at best. So far, conservative groups including the Club for Growth and Heritage Action have embraced the latest plan, while the American Medical Association, the seniors’ advocacy group AARP and many House and Senate Republicans are coming out against it.
Trump may believe that a win is a win, and that regardless of what the bill finally looks like, he will embrace it as his own. Yet the plan as it has evolved in the House is far from what he promised during the campaign. The latest version if enacted could put major constrains on the availability of health insurance and Medicaid, and result in millions of people losing their coverage.
If that proved to be the case, the prospects of a voter backlash would be great. And Trump might eventually come to regret having delivered on his important campaign promise.
The original plan crafted last month in secret by House GOP leaders and committee chairmen and Trump administration officials sought to transform Obamacare into a more conservative, market-oriented system with a radically different approach to subsidizing coverage and a major push to roll back expanded Medicaid for the poor.
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Trump and Ryan voiced confidence the plan would roar through the House with major GOP party unity. But the air went out of the balloon after the non-partisan Congressional Budget Office concluded that 24 million Americans would lose their health insurance under the plan over the coming decade.
And Ryan had to pull the plug on a vote March 24 in the face of a rebellion from Freedom Caucus members who complained the plan didn’t go far enough to dismantle Obamacare mandates, and moderates who feared the bill went too far in stripping their constituents of coverage.
MacArthur subsequently forged an alliance with Freedom Caucus leaders, including Reps. Mark Meadows of North Carolina and Jim Jordan of Ohio, to craft an alternative designed to bring more conservatives aboard, even at the cost of alienating many moderates who would be needed to pass any measure without Democratic support.
MacArthur introduced an amendment that would allow states to opt out of certain requirements of the Affordable Care Act, including one that requires insurers to provide ten “essential benefits” in their policies, including maternity care, prescription drugs and mental health treatment. In that way, insurers could save money and lower their premiums and co-payments by offering skimpier plans.
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But another provision proved to be a bridge too far: MacArthur’s amendment would also effectively do away with the Obamacare prohibition on insurers charging higher premiums based on an applicant’s health status
The new GOP proposal would authorize states to seek waivers from the ban on discriminating against consumers with pre-existing medical conditions – the very provision that Trump had promised to protect. States that received the waiver could allow insurers to charge higher premium rates for sick applicants, although only if the consumer had gone without coverage for at least 63 days in the previous 12 months.
Republicans insist that their waiver approach would help bring down premium costs for healthier and younger consumers, and that their amendment also would provide billions of dollars in federal funding to operate “high risk pools” to help subsidize insurance costs for sicker individuals.
Politico reported Thursday that many moderate Republicans are withholding their support for the latest plan out of concern that it would hurt people with preexisting medical conditions. Some are saying that rather than improving the original plan, the MacArthur amendment is putting more Americans at risk of losing their health insurance.
“My concern has always been and what a lot of us talked about: people with pre-existing conditions, the elderly,” Rep. Mario Díaz-Balart (R-FL) told Politico. “How this makes the original bill better? Where is the part that is better for the folks I’m concerned about it? I’m not seeing it at this stage.”
Meadows and other proponents of the latest GOP health care plan say they haven’t given up, and raised the possibility that the House would vote on the measure next week. But House Minority Leader Nancy Pelosi (D-CA) warned that Trump and Republicans in Congress will have “doo-doo stuck to their shoe for a long time” if they pass the revised American Health Care Act.
