Faced with that reality, McConnell could have started over and had the Senate develop its own legislation, perhaps even working with Democrats on a bipartisan alternative that could withstand the test of time. Instead, McConnell put a plan in place to pass something close to the House bill using three simple tools: sabotage, speed and secrecy.
? Sabotage: Given the unpopularity of the AHCA, Republicans have just one argument: Obamacare has failed. The GOP premise is "bad" beats "dead." The problem is the facts don't support this. Medicaid — which accounts for the bulk of the ACA coverage expansion — is successful, popular and bipartisan. The ACA's individual insurance exchanges got off to an uneasy start, but after five years, insurer filings and independent reports all point to profitable insurers and stable or stabilizing markets — at least until President Trump intervened to rattle insurers.
Taking advantage of those now well-documented efforts to sabotage the ACA, McConnell is reportedly telling his members they have no choice but to pass a replacement. By acting fast, McConnell hopes to minimize the continuing and mounting evidence of sabotage as insurers file rates in places such as North Carolina and Pennsylvania that explicitly break out the specific impact of Trump's sabotage.
? Speed: As he watched House members scrupulously avoid constituents while on recess, McConnell clearly recognized that his best bet would be to hold a vote before the July 4 recess in hopes this would minimize pressure on vulnerable senators such as Nevada's Dean Heller — who won his seat by a mere 12,000 votes in a state where more than 200,000 will lose Medicaid coverage.
So last week McConnell deployed Rule XIV, a fast-track procedure that bypasses the committee process and moves the bill directly to the floor. Just as in the House, we're on track to have a vote with no hearings (there were more than 100 for the ACA). Knowing the coverage loss will be significant, McConnell plans to vote within only days, or possibly even hours, of the release of the CBO score. Moving fast leaves opponents, and the public, with no time to catch up to the details.
? Secrecy. None of this will work if the content of the bill cannot be kept secret for as long as possible. A small group of Republicans is amending the House bill behind close doors. And for all the talk of having the Senate start over and fix the bad House bill, their reported changes appear to be minimal, and to follow the blueprint laid out by Senate Majority Whip John Cornyn (R-Tex.) that: "80 percent of what the House did we're likely to do." The ACA's expansion of Medicaid would end. The caps on Medicaid spending imposed by the House bill would remain. With state approval, insurers would still be able to offer Swiss cheese policies that drop benefits people with preexisting conditions need most.
The secrecy is also necessary for backroom deals. Given the opioid crisis in her state, one would think the AHCA's severe Medicaid cuts would mean Shelley Moore Capito (W.Va.) would never support it; the majority of opioid treatments in her state are provided by Medicaid. Similarly, one would think there is no price that would cause Lisa Murkowski (Alaska) to sign on to a deal whose consequences for her state would be worse than any other state. But McConnell is counting on being able to buy their votes relatively cheaply: possibly with a small "opioid fund" and an extra few years before the Medicaid expansion ends in certain states.
Of course there's a better way. Not long ago, Republican Sens. Bill Cassidy (La.), Susan Collins (Maine) and Capito talked about finding solutions that would lead to more people covered, not fewer. That's an approach that could bring many Democrats to the table. Given the Senate's narrow margins, by voting no, the three of them or others have the power to change the course we're on and put health-care reform on a path to long-term political stability. And McConnell himself might not even mind. Something short of 50 votes will preserve the Senate's role as our deliberative body with the good judgment not to bow to the political winds, particularly when the country needs its checks and balances to work like never before.
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