I can’t figure out what Paul Ryan thinks he’s up to on Obamacare replacement.
The basic political problem he faces is simple: Republicans are in agreement that Obamacare should be repealed and replaced, but their agreement breaks down over what it should be replaced with.
A bill that keeps too much of Obamacare’s spending will alienate conservatives who believe they were sent to Washington to pass a “full” repeal. A bill that cuts too much makes moderate Republicans squeamish, especially those who come from states that depend on expanded Medicaid.
So The Wall Street Journal reported early this week that Ryan’s plan is to steamroll those objections: Bring a bill that comes down somewhere in the middle to the floor, and dare members on the conservative and moderate ends of his caucus to vote no.
And this week, Republicans members of the House Energy and Commerce Committee are working on a repeal and replace plan in secret — a fact that has drawn objections not just from Democrats who want to protect Obamacare, but also from Sen. Rand Paul, the Republican from Kentucky, who fears the plan they are developing will amount to “Obamacare-lite.”
Paul joined many House Democrats on Thursday in demanding the release of the draft bill. He brought a photocopier with him through the halls of the Capitol complex, saying he wanted to make copies of the bill widely available.
Objections from the right and the left
The problem with Ryan’s approach is, sooner or later, the committee has to release the bill text, at which time it will face predictable objections from both the right and the left.
You can see some of the likely objections from Republicans’ right flank in Thursday’s tweets from Paul. Conservative Rep. Mark Meadows of North Carolina asked, “What is conservative about a new entitlement program and a new tax increase?” He was referencing provisions of an earlier “discussion draft” for the bill.
On the other end of the caucus, you have members like Charlie Dent of Pennsylvania. They seem awfully nervous about undermining the Medicaid expansion, which is important for their states’ insured populations and also for their states’ budgets. Dent has been critical of “haste” and “arbitrary deadlines” for repealing Obamacare.
Speaking of haste, Rep. Chris Collins says the Energy and Commerce Committee may even vote on the bill before they have a score from the Congressional Budget Office telling them what it will cost and how many people it will cover.
This would be sort of a bizarre thing to do. But it also won’t keep moderate Republicans from getting squeamish when the CBO score, which is likely to show millions losing insurance, comes out before the full House votes on the package.
Ryan’s theory seems to be that the immediacy of a vote on a replacement bill, and the need to keep the promise to “repeal and replace Obamacare,” will force his members to set aside their objections.
Indeed, based on his past experience trying to herd the Republican caucus, former Speaker John Boehner says he doesn’t expect repeal and replace to happen.
The big problem is the Senate
In recent years, fights over “must-pass” legislation in the House have tended to end with Republican leadership having to shift bills far to the right to secure passage, which would tend to mean greatly reducing spending and subsidies.
Maybe, by doing that, Ryan will be able to get a bill through the House. But what about the Senate, where the Republican majority is narrower and the Senate caucus is more moderate?
Several Republican senators have expressed significant reservations about whether the replacement plan will do enough to protect those who depend on the Affordable Care Act. They have been adamant about the need to have a full replacement in place before repealing Obamacare.
Republican Sen. Lisa Murkowski, for example, says she won’t vote for a package that scraps the Medicaid expansion as long as Alaska lawmakers want it.
The discussion draft House bill that leaked last week would likely have been unacceptable to both Paul
and Murkowski — handing out too many subsidies for his taste, and cutting spending on Medicaid too much for her standards.
This makes me think it’s very unlikely that a bill that can be rammed through the House can also pass the Senate — and therefore that it is unlikely that Ryan’s strategy will lead to enactment of legislation.
But maybe that is what Paul Ryan is up to.
As Brian Beutler of the New Republic notes, forcing a bill down the throats of House Republicans only to see it die in the Senate is not an effective strategy for repealing Obamacare. But it could be a very effective strategy for getting conservative voters to blame the Senate, not the House, for Republicans’ failure to repeal Obamacare.
The missing variable is Trump
The one thing that would lead me to change this view that Republicans are not headed for repeal would be if Donald Trump weighed in strongly to pressure Republicans in both chambers to vote for a bill they have major reservations about.
Complicated legislation involving lots of tradeoffs tends to pass when the president brings pressure to bear on his party in Congress, as with the Medicare prescription drug benefit under George W. Bush or the Affordable Care Act itself.
So far, Trump has shown no inclination to do that — in fact, he has warned his party against the trap of taking ownership over problems in the health care system. Politically, he’s wise to talk a big game about healthcare while avoiding getting his fingerprints on it too much. But it’s not a strategy that augurs for actual repeal and replacement.
This is an opinion column. The thoughts expressed are those of the author.
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