<p class=There is no need to take up too much space here reviewing the ugly particulars of the American Health Care Act (AHCA) or the devastating consequences if something like it eventually becomes law. You can find excellent roundups here and here. It is true there are some less-well-understood implications of the legislation, such as the fact that if any state receives a waiver from the Essential Health Benefits requirement it could affect coverage for people with employer-sponsored insurance in every state. However, by now, the main provisions of the bill – a dramatic scaling back of the assistance that makes health insurance affordable – are well known.

How did a worse-than-bad bill pass the House after defeat in round one?

So instead of a bill recap, let’s focus on how what was arguably an even worse bill than the one that failed in the House a few weeks ago managed to pass, and how that story helps inform what might happen next in the Senate. The unfortunate but inescapable conclusion is that it is precisely because the bill was worse that it was able to pass.

The intensity and consistency of the farthest right members of the House Republican caucus was not matched by the more amorphous and individualistic concerns of the House “moderates.” In the AHCA’s initial outing, the more centrist members of the Republican caucus did not have to shoulder full responsibility for the failure of the bill to advance. However, once the Freedom Caucus got on board by further undermining consumer protections, the full weight of blocking repeal fell entirely on the “moderates,” who became susceptible to the following arguments:

  • If the House didn’t advance a bill, the optics would be bad. After all, they had been promising “repeal and replace” for seven years.
  • Even if the “replace” part was not what House members had in mind, the Senate would fix it later.
  • Cutting taxes in the health care bill would help them deliver a big tax cut to the wealthiest households and make their tax code overhaul easier.

These arguments, combined with the fig-leaf of protection the Upton amendment provided, and perhaps not wanting to be on the wrong side of leadership, Trump and the Koch machine all at once, gave just enough members the cover they were looking for. They could ignore the massive protests back home, pass the bill and celebrate in the White House Rose Garden.

Don’t assume the Senate will “save the House from itself.”

There are a few takeaways from this story as we contemplate the future of ACA repeal in the Senate. First, disregard the common assertion that the Senate will “save the House from itself,” or at least take it with a very hefty dose of salt. Although the Senate has its own dynamics that differ from the House’s, there are also key similarities. There are also procedural hurdles to overcome if “fixing the bill” extends beyond adjusting the insurance market changes to fixing the Medicaid provisions and restoring the cuts in premium assistance.

With respect to political dynamics, the Senate has its own right-versus-far-right divide. And just like in the House, the far-right members (Cruz, Paul and Lee) are much more comfortable acting as spoilers than the so-called moderates who don’t like the ACA, even if the changes they seek are somewhat more modest. As it turned out, the House “moderates” were a pretty cheap date. There is reason to be concerned that many in the Senate who have expressed concerns will settle for modest, and mainly cosmetic, changes. It’s also worth noting that Cruz and Lee are both on the work group drafting the Senate bill, but none of the most consistent critics – Collins, Cassidy, Murkowski or Capito – are included.

This is particularly true with respect to Medicaid. Under the AHCA, not only would cuts in reimbursement force many states to abandon the coverage gains of recent years, but capped funding also would squeeze states’ abilities to maintain services for children, people with disabilities and older adults. (These are the cuts Paul Ryan has been dreaming of making since long before the ACA ever became law.)

However, despite all of the talk about the Senate writing its own bill, as a technical matter they are writing a substitute, not a truly new bill. The difference matters. Whatever changes the Senate makes cannot have any less of a net deficit reduction than the House. If the Senate wants to fix the Medicaid section, or for that matter, do better than the House with respect to premium tax credits, they also have to come up with the money – either by scaling down the tax cuts for the rich or by coming up with new spending offsets.

While a few Senators have expressed the opinion that most of the ACA taxes need to stay to pay for coverage, any move in this direction would probably lose at least all three of the farthest right members, and probably many more. Coming up with a new offset is hardly any easier, and could be even more problematic.

Senators who object to the Medicaid provisions of the bill have mainly expressed concerns about the timing of the phase out of the enhanced match for the Medicaid expansion. But if they seek to delay the phase out (let alone restore the enhanced match), the most likely place for them to go for an offset would be to cut the core Medicaid program even MORE. This would be a bad deal for beneficiaries. The end result would be that the expansion still goes away while the additional Medicaid cuts make things worse for seniors, people with disabilities and low-income families.

Added to these problems is the fact that not many Republican Senators are up for reelection in 2018, which may attenuate their sensitivity to voters concerns.

Keep up the pressure!

Although the situation is serious, it is by no means hopeless. It is likely that at least two Senators are already locked into opposition, (probably one from each camp – Collins and Paul). It only takes one more dissenter from the moderate wing to force changes. In addition, a new CBO score will remind senators and the public just how bad this bill is. Finally, the opposition was still gathering steam as the House vote was taking place. We cannot discount the breadth and power of this opposition.

To sum up, making improvements in the AHCA in the Senate will be much harder than many people imagine, but it is not impossible. Now is the time to redouble our efforts to mobilize resistance to the current legislation if we are going to avoid a catastrophic rollback of health and economic security.  

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.