The revised American Health Care Act was released last night and despite Paul Ryan’s promises to fix some elements of the plan, it has actually probably gotten worse. Kevin Drum gives us the rundown on the significant changes:
- Adds $75 billion to reduce premiums for old people. But in an awesome display of legislative farce, the amendment doesn’t actually set up the tax credits. It just tells the Senate to do it. So House Republicans have to vote for a pig in a poke.
- Repeals Obamacare taxes a year earlier.
- Increases Medicaid reimbursements for the elderly and disabled.
- Deletes a provision that allows people to transfer unused tax credits into a Health Savings Account. Apparently some activists were afraid this might indirectly allow tax credits to be used for abortions.
- Allows states to establish work requirements for Medicaid.
- Allows states to take Medicaid as a block grant, presumably so they have more flexibility to use Medicaid money any way they want and more authority to tighten requirements for the poor.
In addition, in particular language designed to win over upstate New York Republicans, about $2.3 billion in Medicaid spending will shift from those upstate counties to the state, blowing a hole in the state budget. Elements that Paul Ryan indicated might be changed such as the late enrollment penalty and the age rating ratio remain unchanged, and premium relief for older workers is allocated as a tax deduction, thereby increasing deficit reduction, in order to hopefully win House conservatives, with the knowledge that the Senate will turn that into a tax credit in their version of the bill, if there is one.I’m not sure the deficit hawks in the party will fall for that one.
The GOP has promised that CBO will be able to score this bill before the vote on Thursday but it is doubtful that it will change its previous results in any significant way. In fact, with the block grant option and work requirement for Medicaid, it may actually increase the number of uninsured. The shift of costs from counties to the state will also probably add to the uninsured as New York may not be able to fully fill that new budget gap.
With the rollback of the Obamacare taxes a year earlier and the recognition that there will be another $75 billion or more in tax credits, it is also hard to see how much deficit reduction will remain. The original proposal came to a savings of $337 billion over 10 years. This new bill will be far less than that now. And the $600 billion in tax cuts for the top 1% will actually increase. As Larry Levitt from the Kaiser Family Foundation says, “This ACA repeal bill is looking more and more like a tax cut and Medicaid bill.” Considering that Paul Ryan has been dreaming about gutting Medicaid since he first starting drinking beer, that’s hardly a surprise.
Already, the House Freedom Caucus is saying they have enough votes to kill this bill and Trump headed to Congress this morning in order to twist some arms. He held a meeting that lasted maybe 30 minutes and apparently threatened Republicans in his usual manner saying, “I honestly think many of you will lose your seats in 2018 if you don’t get this done”. Of course, some of those listening fear they will lose their seats if they do get this done. And I’m not sure that is the kind of deal-making that is going to get this bill across the finish line. Ryan and Trump will be in some ways fighting for their legislative lives. For Ryan, failure to shepherd this bill through the Republican-controlled House could very well mean the end of his stint as Speaker. For Trump, the inability of his ACA replacement, no matter how flawed and at odds with his prior promises, could be a mortal blow to his legislative agenda almost before it begins. Both will be pleading with recalcitrant House members to at least clear this hurdle with the promise there will be another vote if and when the Senate passes their own bill and the two bills get merged into one in conference.
But the resistance to this bill is enormous and Republicans around the country are feeling the heat. Trump himself is a damaged President, already under investigation for collusion with the Russians during the campaign. On the other hand, Trump is still enormously popular with his Republican base and that still means a lot to the Republicans who represent those districts. Right now, it does not look like Ryan has enough votes to pass the bill but if he and Trump can make the vote close, they will be able to exert enormous pressure on the remaining holdouts to cave. But if there is a block of Republican dissenters that can remain solidly together, Trump and Ryan will have difficulty. GOP House members in a pack are safe but individual strays will get picked off one by one.
For Democrats around the country, the next two days of relentless resistance will be crucial. According to this handy NY Times interactive feed, you can track where the vote stands. There are 23 Republican House members who represent districts that were won by Hillary Clinton. Those members need to hear from Democrats every second for the next two days. With those votes alone, this bill will go down to defeat. Stephen Wolf at Daily Kos provided the list of those representatives below:
Time to get working and kill this horrendous bill right now and, at the same time, damage Trump further and complicate the GOP legislative agenda going forward.
[I’ve also written about this and other issues on my personal blog at tidalsoundings.blogspot.com]