March Madness

Exciting. Fascinating. Interesting. These are some of the euphemisms I use to describe what it’s like these days to be an academic whose focus is the politics of health reform. Madness is a better word.

In the past 24 hours alone, Republican leadership has done everything they have attacked Democrats for over the last seven years. They are rushing legislation without giving the public or even each other time to know what they are voting on. It says a lot that Republicans passed a bill through multiple committees without a CBO report and that they are pushing to vote on the amended bill without an updated CBO score. They are adding sweeteners reminiscent of the cornhusker kickback. They are creatively spinning the implications of their reform for regular people. The campaign ads make themselves with quotes from President Trump and others far more egregious than “if you like your insurance you can keep it.” Ezra Klein says the AHCA could be Trump’s Iraq War because it was “sold on lies, poorly planned, deadly to thousands, and a catastrophe for its authors.”

The changes happening in the House right now make it clear that the Republican plan is a political solution to a political problem, not a policy solution to a policy problem . After seven years of campaigning on repealing Obamacare, Republicans need to pass something – ANYTHING – to give them enough cover to move on.

In the past 24 hours alone, Republican leadership has done everything they have attacked Democrats for over the last seven years.

“A Big Fucking Deal”

The 7^th anniversary of the ACA’s passage has been honored in lots of different ways. Joe Biden returned to Capitol Hill yesterday to join Nancy Pelosi, Chuck Schumer, and other Democrats fighting to save the law. Medicaid enthusiast and former HHS staffer Emma Sandoe baked her annual birthday cake for the law, this time adding a 7^th layer.

One of the main reasons Paul Ryan seems to be pushing so hard for the AHCA vote to happen today seems to be for the symbolic effect of repealing the ACA on its anniversary. That would be a pretty big deal. But so would the AHCA’s defeat.

Political Realities

As I write this it is unclear whether the AHCA passed the House or even whether Ryan actually goes ahead with the vote. (Update at 5pm on 3/23: The vote has been postponed, supposedly until tomorrow morning). There are reports that he is willing to play a high-stakes game of chicken by holding the vote even if he is unsure he will win, daring conservative and moderate Republicans to follow through with threats to vote against Obamacare reform.

Regardless of what happens to the AHCA in the House, there are six political realities that will drive the next chapter in the fight over health reform:

1) Most of the compromises designed to win support in the House make it harder to pass the bill in the Senate. It will be very hard for moderate Republican senators in states that have expanded Medicaid to vote for the AHCA – especially in states with Republican governors advocating for stability.

2) Paul Ryan knows this. The goal isn’t to convince the Senate to pass this version of the AHCA. The goal is to make it to a conference committee where the true compromises will happen. That final negotiation is easier if the House and Senate bills are close to each other, but passing just about any version of an ACA repeal and replace bill gets Republicans to that crucial juncture.

3) The clock is ticking. Republicans are well ahead of schedule compared to where Democrats were at this point in 1993 and 2009 in terms of moving legislation. They may pay the price for moving too quickly, not doing the work to build consensus. But passing such a complex law will only become more difficult the longer they wait, distracting from other parts of the Trump/Ryan/McConnell agenda and becoming increasingly ensnared in midterm politics. If the AHCA fails it is hard to imagine Republicans regrouping in such a way to pass something else. Republicans are highly aware that Democrats suffered historic losses in 1994 and 2010 after spending so much political capital on health reform. However….

4) The midterm map in 2018 favors Republicans to such a great extent that Democrats will have a difficult uphill battle to take back control of either chamber, regardless of the AHCA’s outcome. With some exceptions, Republicans are more likely worried about challenges from within their own party than from the left. Will a Republican primary opponent criticize the incumbent for taking away insurance from millions of people?

5) The most important person in the fight over health reform is not Donald Trump, Paul Ryan, or Mitch McConnell. It’s Elizabeth MacDonough. As Senate Parliamentarian she will be called on to make crucial rulings about issues such as whether the provisions added at the 11^th hour prevent the Senate from considering the AHCA through the reconciliation process. If not, Republicans will face tough choices about how to maintain conservative support while taking elements back out, whether to try to win over some Democrats to get to the filibuster-proof majority, or whether to go nuclear and change Senate rules governing the filibuster.

6) Republicans now own the problems of the U.S. health care system. Even successfully passing a law won’t help them in the long-run given that nothing they are proposing solves the underlying problems of cost and access to care in America.

While watching the Michigan game tonight (Go Blue!) I will have an eye on C-SPAN and my Twitter feed. I’ve restrained myself from over-extending the analogy between health reform and the NCAA tournament, but both are turning out to be pretty exciting – or dare I say, maddening.

Feature image: North Charleston, Boeing 787-10 rollout with President Trump, used under CC BY-SA 2.0, cropped from original

Cake photo by @emma_sandoe