The American Health Care Act that narrowly passed out of the House this month cuts $880 billion from Medicaid — but that won’t affect anyone’s coverage.
It keeps the GOP’s promise to repeal the Affordable Care Act — but doesn’t really repeal the Affordable Care Act.
It passed after conservatives demanded that it allow states to end some mandated benefits — but states aren’t actually going to do that.
Such pronouncements from Republicans in the days since they passed the AHCA and celebrated in the Rose Garden reflect a deep struggle to sell the bill at home. The bill falls short of the GOP’s long-standing promise to repeal and replace the Affordable Care Act. But most Americans now oppose the “full” repeal that so many Republicans have pledged to make happen year after year.
That means these lawmakers face two potential backlashes: one if opponents of Obamacare perceive that the bill does not go far enough, and another from Americans worried that the bill would eliminate their coverage.
The result has been a confused sales effort — and a series of flat misstatements and contradictions about what’s actually in the bill.
It’s a risky strategy — especially in front of the skeptical crowds and interviewers Republicans have been speaking to in recent days. On Wednesday, Rep. Tom MacArthur (R-N.J.) spent nearly five hours answering questions from a disgruntled audience of constituents, some of whom spoke at length about what Medicaid meant in their communities. MacArthur was blown back by laughter when he argued, as House Speaker Paul D. Ryan (R-Wis.) has, that caps on per capita Medicaid funding would leave the system stronger.
“I am trying to save a system so it continues to help you,” he said. “I am trying to make sure Medicaid is strong enough to continue.”
Later, MacArthur argued that the tax cuts in the bill were “for everybody” — but when a constituent calculated that MacArthur’s own savings would amount to $37,000 if the bill passed, the congressman agreed that the bill’s large investment tax cut was not going to benefit everyone equally.
Many lawmakers have admitted that they didn’t read the whole document before voting on it early this month. Some concede that the bill is flawed. Some have assured voters that the Senate will fix it now that the upper chamber’s turn has come to grapple with what increasingly looks like the impossible promise they began making to voters soon after Obamacare passed in 2010.
The optimistic spin, shaped by polling but often concocted on the spot, reveals how a process that President Trump once pledged to get done “very quickly” has become a roiling political problem. Republicans are being advised to lead with attacks on Obamacare’s implementation, then pledge that the final passage of their bill will alleviate those problems by November 2018.
In a memo circulated this week by the conservative firm WPA Intelligence, Republicans were advised that “full repeal,” the campaign promise since 2010, is neither popular nor possible. In Georgia’s solidly Republican 6th District, where Democrat Jon Ossoff is trying to win Health and Human Services Secretary Tom Price’s former congressional seat, supporters of keeping the ACA outnumbered opponents by a narrow 10-to-9 margin.
The current bill would allow states to jettison two of the ACA’s consumer protections: a rule forbidding insurers to charge customers with preexisting medical conditions more than other individuals, and a rule that requires insurers to include specific “essential health benefits” in all plans sold to individuals and small businesses.
The final House version also would increase new pots of money the bill would give states to try to control insurance prices. At the last minute, $8 billion also was added to help people with preexisting medical problems who live in states that revert to letting insurers charge such customers higher rates. Health policy experts have said it is not nearly enough money to cover increased costs for those people.
In framing the bill, many Republicans are following the cheerleader-in-chief, a former supporter of single-payer health care who continues to talk as if the AHCA provides universal coverage. “You’re going to have absolute guaranteed coverage,” Trump told the Economist in an interview published this week.
Democrats — with many memories of being hammered over the ACA and blamed for every lost or altered private insurance plan — don’t think Republicans can pull it off. Two hundred and seventeen House Republicans voted for the bill, but fewer than 20 are using the week-long recess to hold town hall meetings.
“The president has amazing reality-bending powers for the 30-something percent of people who support him,” said Rep. Ted Lieu (D-Calif.), who is helping the Democratic Congressional Campaign Committee recruit challengers to the seven pro-AHCA California Republicans who represent districts that rejected Trump. “He doesn’t bend reality for the majority of Americans. In a year from now, people will know if they have health coverage. It doesn’t matter what any of us say.”
What many Republicans say is sometimes hard to square with the facts. The Congressional Budget Office will not produce a cost estimate for the AHCA until May 22, but over the weekend, Ryan spokeswoman AshLee Strong argued on Twitter that the bill had been “scored twice” — referring to analyses of the bill before amendments.
At some town halls, Republicans have awkwardly argued that even the process of passing the bill was more transparent than voters had thought. During a Tuesday event in Riverbank, a small town in his Central California district, Rep. Jeff Denham (R-Calif.) assured constituents that he knew what was in the legislation.
“I don’t commit to things unless I read the final version of the bill and what the amendments are,” Denham said.
“You read the entire bill?” asked one constituent, referring to the American Health Care Act.
“It was read in committee; it was read a couple of times,” Denham said. “Bipartisan. Both parties. Working together.”
A cameraman from the Modesto Bee captured the exchange and the groans, which quickly went viral. No Democrat had voted for the legislation. Senate Republicans, who are working on their own bill on a separate timeline, have occasionally been confused by the Houses’s spin attempts.
“They didn’t score the more recent version, right?” said Sen. John Thune (R-S.D.), who is working on language to make the bill’s tax credits more generous. “We don’t know how much is available to modify the tax credit from the House bill. We know what they were proposing to have in there but we haven’t seen an official CBO score.”
Ever since the first CBO score, which foresaw 24 million more people without coverage if the AHCA were to be implemented, the bill has been a tough sell, of New Coke proportions. In polls taken since the House moved the bill, voters with a strong negative opinion have vastly outnumbered voters with a positive opinion. A study released Wednesday by YouGov found 50 percent of voters opposed to the bill and 33 percent in favor. Just 11 percent of voters had a “strong” positive opinion — 34 percent stood on the other side.
“This is truly an unforced error of the first order, politically and economically,” tax-cut advocate and frequent Republican candidate Steve Forbes wrote in his family’s namesake magazine this week. “If the Republican Senate doesn’t fix the RyanCare error . . . Nancy Pelosi will be Speaker of the House of Representatives in 2019.”
In interviews with conservatives, Ryan has described the bill’s biggest win as the block granting and cutting of Medicaid. But Republicans have frequently downplayed its importance.
“We believe the Medicaid population will be cared for in a better way under our program because it will be more responsive to them,” Price said on CNN last weekend.
“If you’re currently getting your health insurance through Medicaid, nothing’s going to change,” Rep. Rod Blum (R-Iowa) said at a town hall meeting on Monday.
The bill would substantially alter care for millions of people on Medicaid, both by ending the expansion of the program to people slightly over the poverty line, and by tying federal Medicaid spending to the consumer price index.
Some messaging may assume that voters are less concerned with Medicaid spending and overall coverage numbers than Democrats are. In the WPA Intelligence study, Republicans in tough races were advised to frame the election as a choice between “Obamacare” and something that would keep the parts of the ACA that they liked while making coverage cheaper.
“While the typical sources focus on coverage, voters care a lot more about their health insurance costs than they do about the total number of people covered by health insurance,” the firm advised. “If Republicans succeed in lowering health insurance costs by reducing regulations, increasing competition, and giving Americans more choices, then they are more likely to benefit than to suffer from an Obamacare repeal.”
While headlines back home said that the House had “repealed” the ACA, Republicans have admitted that the AHCA would not pull that off.
“It’s important that we’re clear with them, that it’s not a full repeal,” said Rep. Scott Perry (R-Pa.) in a roundtable with reporters before the vote. “I think they’ll give us a bit of latitude, working under the rules of reconciliation. When they see their premiums go down, I hope they’ll give us the time to finish this and actually repeal the bill.”
Ekise Viebeck contributed to this report.