To hear House Speaker Paul D. Ryan tell it, we are all misunderstanding the scale of the Republican plan to replace Obamacare. During his sleeves-rolled-up presentation last week, he explained, not for the first time, that the American Health Care Act is simply part one of a three-part plan.
Those parts? Part one, as noted, is the AHCA. In part two, Secretary of Health and Human Services Tom Price takes a number of executive actions, such as deregulating the marketplace. Part three, Congress passes more bills to flesh things out. Simple enough.
On Tuesday, White House press secretary Sean Spicer reminded the assembled press corps that the AHCA was only part one of the plan, and he did so for a very specific purpose: to undercut the problematic (for Republicans) Congressional Budget Office analysis of the AHCA that came out Monday.
“CBO coverage estimates are consistently wrong,” Spicer said, “and, more importantly, do not take into consideration the three — the comprehensive nature of this three-pronged plan to repeal and replace Obamacare with the American Health Care Act.” In other words, the CBO’s analysis looked only at part one of the plan, not all three parts — and, therefore, its analysis should be considered suspect.
In theory, that is a fair argument. In reality, though, there are two very good reasons that the CBO didn’t include those other two prongs. The first is that the CBO evaluates legislation, not multipart strategies involving executive action. The second reason, however, is the more problematic one: The other two prongs don’t really exist in any meaningful way.
There’s a reason that the Republican leadership is approaching health-care reform the way that it is. We can explain this best by looking at each prong.
Prong one: The AHCA. The critical aspect to the passage of the AHCA is that Republicans hope to use the reconciliation process to move it through Congress. This is a unique congressional tool that has two features that are important to understand. The first is that the process was developed to focus on reconciling conflicting instructions affecting the budget. Therefore, any reconciliation legislation has to meet specific criteria focused on the budget, including that certain increases to the deficit that might result from the legislation would be subject to a 60-vote threshold in the Senate.
Which reveals the other major feature that’s important to know: If a bill meets the various criteria established under reconciliation, it can’t be filibustered. Meaning that the majority of Republicans in the Senate are more than enough to pass it without any input from the Democratic caucus. And that, more than anything, is why Ryan and the Republicans want to use reconciliation to move the repeal forward.
Prong two: Price acts. It’s also why there have to be two other prongs. Since some changes the Republicans want to make can’t be included in a reconciliation deal and others would trigger the need for 60 votes, the Republicans have offshored some things to Price.
A White House fact sheet describes some of those things in broad strokes. “Loosening restrictions on the financial structure of insurance plans offered on the Obamacare exchanges, which will give individuals and families access to lower premium options,” for example. Or, “Improving choices for patients and putting downward pressure on prices by curbing abuses of the enrollment processes and encouraging full-year enrollment.”
Even if the CBO wanted to evaluate those goals, a lot more specifics are required.
Prong three: Congress passes additional legislation. Spicer described some of these during his news conference on Tuesday.
Possible other reforms include “streamlining the process at the FDA, so that innovative and lower-cost medicines can get to patients faster, allowing health insurance to be sold across state lines, which increases competition and decreases costs,” he explained. Both of those are listed on the White House fact sheet, too. (Ryan also used the state-line legislation as an example of something that had to be in the third prong during his presentation. “One conservative group is saying, ‘By golly, you better put shopping across state lines in this bill or else we’re not going to support it,'” he said. “Guess what, Chad? If we did that, we wouldn’t be able to pass this bill. It would be filibustered in the Senate. It wouldn’t even come up for a vote.”)
It’s not yet clear, though, what legislation is intended to be part of this third prong, or if it even exists. If there were a bill for the CBO to analyze — say, something that added 24 million people back to the pool of insured people by 2026 — it could be combined with the AHCA analysis to give a fuller picture of the likely effects of the legislation. Without that, though? The Republicans are asking us to trust them that the full meal will be delicious after we read a negative review of the appetizer — and we don’t really know what else is on the menu.
It’s important to note that the Affordable Care Act — Obamacare — also was passed with a combination of reconciliation and more traditional legislation. In that case, though, the reconciliation package included the fixes to the main proposal, not the other way around.
This three-prong approach for the Republicans seems a little like it might be intended to work slightly differently. The problem with this third prong as it stands, of course, is that Democrats can block any legislation in the Senate, thanks to the filibuster. But if the AHCA is passed first, Obamacare will be severely broken — and both Republicans and Democrats will have an incentive to try to figure out how to fix it. That’s the implicit promise in Ryan’s pitch: Once we pass this first thing, we absolutely have to do these other things, too.
If that’s the plan, then the CBO report actually does Republicans something of a favor. If the AHCA passes, that analysis could be precisely the cudgel that’s needed to move that third prong forward past balking Senate Democrats. Its components may not exist now. But if the AHCA passes, the Republicans’ political position suddenly gets much stronger. Regardless of what meal the Republicans drop in front of Americans at that point, the choice may be to swallow it or to starve.