As Republicans push out new revisions to save their health-care plan, The Post's Paige W. Cunningham explains the sticking points spurring on the internal fighting over the bill. (Jenny Starrs/The Washington Post)

THE MORNING PLUM:

With multiple media reports suggesting that the drive to repeal Obamacare may be on life-support, House Republicans are rolling out a last-ditch effort to salvage their repeal-and-replace bill before support for it collapses once again. They plan to introduce a new amendment that is designed to give moderates a way to pretend that the GOP bill won’t harm people with preexisting conditions — and thus, a way to support the bill in the numbers needed to pass it.

In reality, the new amendment is unlikely to insulate moderate and vulnerable Republicans from potent political attacks if they do support the bill, since it will be pretty much just as cruel in human terms — on multiple levels — as the current one is. Unfortunately, with moderates under all kinds of other pressures to support the bill, the possibility of this working with just enough of them can’t be ruled out.

The new amendment, which is being championed by Rep. Fred Upton (R-Mich.) — who made a huge splash by opposing the bill yesterday — would essentially add $8 billion of funding over five years in addition to the so-called high-risk pools, which are supposed to function as a safety net for people with preexisting conditions who lose coverage as a result of the GOP bill. The Republican plan would gut protections for people with preexisting ailments, because it would allow states to waive the prohibition on insurers from jacking up premiums for them — a prohibition that’s called “community rating” — which could lead to soaring costs and many of them getting priced out of the market entirely.

President Trump promised on April 30 that new GOP health-care legislation will preserve coverage for people with preexisting medical conditions — but critics say that's at odds with his promise to lower premiums. (Peter Stevenson/The Washington Post)

This is a major reason that so many moderates oppose the GOP bill. Even though the bill also requires states that waive those protections to set up some sort of mechanism for people with preexisting conditions — such as high-risk pools — history has shown that they are traditionally underfunded, hit sick people with massive premiums (since only sick people are in the risk pools), and, as a result, leave many uncovered.

Thus the new $8 billion amendment. The Associated Press reports that this $8 billion would be allotted to helping some of those people cover some of those costs so that fewer go without coverage. But as the AP notes, the sum is a paltry addition relative to what is currently in the bill, and that sum is already being derided as woefully inadequate — so it’s hard to see how this $8 billion changes much:

Upton said the proposal would provide $8 billion over five years to help some people with pre-existing medical conditions pay costly insurance premiums … There’s already around $130 billion in the legislation for such assistance, which critics call a fraction of what would be needed for adequate coverage.

That’s a move from $130 billion to $138 billion, and there are tens of millions of people in the United States who suffer from preexisting conditions. I asked Larry Levitt, a senior vice president at the nonpartisan Kaiser Family Foundation, what impact this additional $8 billion would have. He emailed:

If you waive the community rating requirement in the ACA, insurers will charge people with pre-existing conditions astronomical premiums to make sure they’re priced out of the market entirely. $8 billion sounds like a lot of money. But, spread over five years and the potentially millions of people with pre-existing conditions in the individual market with a gap in insurance who would face very high premiums, it won’t go very far.

If a large number of states seek waivers from community rating, this money could maybe help a few hundred thousand people, while millions of people with pre-existing conditions are buying insurance in the individual insurance market or uninsured.

Levitt pointed out that the money could go a lot farther if few states seek these waivers. But the plain fact of the matter is that many red-state lawmakers are very likely to seek them, since they’d presumably either want to relax the Affordable Care Act’s regulations or come under tremendous pressure to do so. In this scenario, then, this additional money would help only a fraction of those with preexisting conditions who could be harmed by the GOP bill.

And let’s not forget the crucial larger context here. Though the discussion is heavily focused on preexisting conditions, the GOP bill would also cut $800 billion in spending on Medicaid, which could leave 14 million fewer people covered by that program, even as it delivers an enormous tax cut to the rich. So, even with this amendment — which itself would probably do little to mitigate the harm to people with preexisting conditions — the bill is still a massively regressive rollback of the ACA’s historic expansion of coverage. Many GOP moderates who opposed the first and most recent version of the bill cited this, too, as a crucial reason for opposing it. So it’s hard to see why this amendment should make a difference, in moral and substantive terms.

Of course, many of these moderates are probably looking for some way to get to Yes, and some may grab on to any kind of “change” to pretend that the bill’s cruel and regressive dimensions have somehow been mitigated. But if so, this could still constitute an enormous political risk. According to the New York Times’ whip count, a large number of House Republicans who currently oppose the GOP bill or are undecided are either moderates, or come from districts won by Hillary Clinton, or both. It’s very hard to see how this $8 billion addition will somehow insulate them from attacks, since the bill still guts protections for people with preexisting conditions and rolls back health coverage for millions and millions of poor people.

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* REPUBLICAN SAYS PEOPLE FEAR DEATH FROM HEALTH BILL: Rep. Thomas J. Rooney (R-Fla.) is leaning toward voting for the GOP health bill, but he’s hearing from a lot of frightened constituents:

“I have a lot of people who call my office on a daily basis who are extremely angry,” he said. “It’s not just because I’m a Republican, but because they are sincerely scared.” Many people with pre-existing conditions fear that they may lose coverage and “are going to die because of a vote we might be taking,” Mr. Rooney said.

It is true that under the GOP bill, a lot of people with preexisting conditions could very well get priced out of the market and lose coverage.

* TRUMP PRESSURES REPUBLICANS: CNN quotes a White House official claiming that Trump called around a dozen Republicans wavering on the bill to try to win their support.

It’s worth reiterating that Trump does not know or care in the least about the specifics in this bill or the human toll it will take on millions. He only wants the “win” of obliterating his loser predecessor’s signature achievement.

* MCCONNELL PREDICTS ‘BIG CHALLENGE’ FOR BILL IN SENATE: Mitch McConnell makes this prediction about the GOP health bill:

“It’s no secret that this has been a big issue in the last four campaigns, and we’re going to continue to work on it,” McConnell said. “And when they send it over here, it’ll be a real big challenge on the Senate side as well.”

You have to think the last thing McConnell wants is for the House to send over a garbage bill that requires GOP senators to say whether they back gutting protections for preexisting conditions.

* DID THE ACA HELP CAUSE A BIG DROP IN BANKRUPTCIES? Consumer Reports calculates a huge drop in the number of declared bankruptcies since the ACA went into effect:

Although courts never ask people to declare why they’re filing, many bankruptcy and legal experts agree that medical bills had been a leading cause of personal bankruptcy before public healthcare coverage expanded under the ACA. Unlike other causes of debt, medical bills are often unexpected, involuntary, and large … The many experts we interviewed…almost all agreed that expanded health coverage played a major role in the marked, recent decline.

It is not often mentioned, but one key goal of the ACA is to protect people from financial ruin caused by illness or injury.

 * REPUBLICANS WANT PROTECTION FROM TRUMP: The president has pushed for the elimination of the Senate filibuster on legislation, but even Republicans have rebuffed this. Carl Hulse reports that they privately want to allow Democrats to help them block Trump:

Majority Republicans then have a ready excuse for not taking actions pushed by the White House that senators of both parties might deem unwise: The Democrats will not allow it. At the same time, Republicans privately acknowledge that eliminating the 60-vote requirement would subject them to extreme pressure from the right to unilaterally pursue an array of conservative initiatives that could ultimately cause a voter revolt.

So the filibuster protects them from both Trump and the right wing. Convenient!

* TRUMP MAY PULL OUT OF GLOBAL CLIMATE DEAL: The Post reports that proponents of pulling out of the Paris climate accord are gaining ground inside the administration, and Trump may do it. But as one climate official under Bill Clinton puts it:

“The Trump team seems oblivious to the fact that climate protection is now viewed by leading allies and nations around the world as a key measure of moral and diplomatic standing. The U.S. would be risking pariah status on the international stage by withdrawing from Paris, and even a fig leaf approach of technically staying in the agreement while ignoring most of its provisions would be better than pulling out altogether.”

As it is, Trump is trying to scrap regulations that make it possible for us to meet our commitment to the deal, and now he may totally scuttle our international climate leadership role.

* AND THE TRUMP TWEETS OF THE DAY: In a pair of late-night tweets, Trump said:

Comey’s announcement of “new” emails — only 11 days before the election — turned out to be nothing whatsoever and helped tip the election to Trump. Also, Comey has publicly confirmed the FBI is investigating that “Trump/Russia story” that Trump claims is a Democratic fabrication.