The Trump Elite. Like the Old Elite, but Worse!
by David Brooks - NYT - March 24, 2017
Legislation can be crafted bottom up or top down. In bottom up you ask, What problems do voters have and how can they be addressed. In top down, you ask, What problems do elite politicians have and how can they be addressed?
The House Republican health care bill is a pure top-down document. It was not molded to the actual health care needs of regular voters. It does not have support from actual American voters or much interest in those voters. It was written by elites to serve the needs of elites. Donald Trump vowed to drain the swamp, but this bill is pure swamp.
First, the new Republican establishment leaders needed something they could call Obamacare repeal — anything that they could call Obamacare repeal.
It became clear as the legislative process rushed forward that there was no overarching vision in this legislation on how to reform health care or even an organizing thought about how to improve the lives of voters. There was no core health care priority that Republicans identified and were trying to solve.
There were just some politicians who wanted a press release called Repeal.
Second, Donald Trump needed a win. The national effects of that win seemed immaterial to him.
His lobbying efforts for the legislation were substance-free. It was all about Donald Trump — providing Trump with a pelt, polishing a credential for Trump. His lobbying revealed the vapidity of his narcissism. He didn’t mind caving to the Freedom Caucus Wednesday night on policy because he doesn’t care about policy, just the publicity win.
Third, the bill was crafted by people who were insular and nearsighted, who could see only a Washington logic and couldn’t see any national or real-life logic.
They could have drafted a bill that addressed the perverse fee-for-service incentives that drive up health costs, or a bill that began to phase out our silly employment-based system, or one that increased health security for the working and middle class.
But any large vision was beyond the drafters of this legislation. They were more concerned with bending, distorting and folding the bill to meet the Byrd rule, an arbitrary congressional peculiarity of no real purpose to the outside world. They were more concerned with what this internal faction, or that internal faction, might want. The result was a pedantic hodgepodge that made no one happy.
In 24 hours of ugly machinations, the Trump administration was willing to rip out big elements of the bill and insert big new ones, without regard to substance or ramification.
House members were rushed to commit to legislation even while major pieces of it were still in flux, when nobody had time to read it, when the Congressional Budget Office had no time to score it, when the effect on health outcomes of actual Americans was an absolute mystery.
As the negotiating process has gone on you’ve seen rank-and-file House Republicans caught between the inside game and the outside game. The logic of the inside game says vote for the bill. Support Speaker Ryan. Don’t defeat a Republican president. But the outside game screams: Oppose This Bill. It’s bad for most voters, especially Republican voters. And nobody likes it.
I opposed Obamacare. I like health savings accounts, tax credits and competitive health care markets to drive down costs. But these free-market reforms have to be funded in a way to serve the least among us, not the most. This House Republican plan would increase suffering, morbidity and death among the middle class and poor in order to provide tax cuts to the rich.
It would cut Medicaid benefits by $880 billion between now and 2026. It would boost the after-tax income for those making more than $1 million a year by 14 percent, according to the Tax Policy Center. This bill takes the most vicious progressive stereotypes about conservatives and validates them.
It’s no wonder that according to the latest Quinnipiac poll this bill has just a 17 percent approval rating. It’s no wonder that this bill is already massively more unpopular that Hillarycare and Obamacare, two bills that ended up gutting congressional majorities.
If we’re going to have the rough edges of a populist revolt, you’d think that at least somebody would be interested in listening to the people. But with this bill the Republican leadership sets an all-time new land speed record for forgetting where you came from.
The core Republican problem is this: The Republicans can’t run policy-making from the White House because they have a marketing guy in charge of the factory. But they can’t run policy from Capitol Hill because it’s visionless and internally divided. So the Republicans have the politics driving the substance, not the other way around. The new elite is worse than the old elite — and certainly more vapid.
The Scammers, the Scammed and America’s Fate
by Paul Krugman - NYT - March 24, 2017
Many people are horrified, and rightly so, by what passes for leadership in today’s Washington. And it’s important to keep the horror of our political situation up front, to keep highlighting the lies, the cruelty, the bad judgment. We must never normalize the state we’re in.
At the same time, however, we should be asking ourselves how the people running our government came to wield such power. How, in particular, did a man whose fraudulence, lack of concern for those he claims to care about and lack of policy coherence should have been obvious to everyone nonetheless manage to win over so many gullible souls?
No, this isn’t a column about whatshisname, the guy on Twitter, who’s getting plenty of attention. It’s about Paul Ryan, the speaker of the House.
I’m writing this column without knowing the legislative fate of the American Health Care Act, Mr. Ryan’s proposed Obamacare replacement. Whatever happens in the House and the Senate, however, there’s no question that the A.H.C.A. is one of the worst bills ever presented to Congress.
It would deprive tens of millions of health insurance — the decline in the number of insured Americans would be larger than what would result from simple repeal of Obamacare! — while sharply raising expenses for many of those who remain. It would be especially punitive for lower-income, older, rural voters.
In return, we would get a small reduction in the budget deficit. Oh, and a tax cut, perhaps as much as $1 trillion, for the wealthy.
This is terrible stuff. It’s made worse by the lies Mr. Ryan has been telling about his plan.
He claims that it would lower premiums; it would actually increase them. He claims that it would end the Obamacare death spiral; there isn’t a death spiral, and his plan would be more, not less, vulnerable to a vicious circle of rising premiums and falling enrollment. He claims that it would lead to “patient-centered care”; whatever that is supposed to mean, it would actually do nothing to increase choice.
Some people seem startled both by the awfulness of Mr. Ryan’s plan and by the raw dishonesty of his sales pitch. But why? Everything we’ve seen from Mr. Ryan amid the health care debacle — everything, that is, except the press coverage — has been completely consistent with his previous career. That is, he’s still the same guy I wrote about back in 2010, in a column titled “The Flimflam Man.”
I wrote that column in response to what turned out to be the first of a series of high-profile Ryan budget proposals. While differing in detail, all of these proposals share a family resemblance: Like his health plan, each involved savage cuts in benefits for the poor and working class, with the money released by these cuts used to offset large tax cuts for the rich. All were, however, sold on false pretenses as plans for deficit reduction.
Worse, the alleged deficit reduction came entirely from “magic asterisks”: claims about huge savings to be achieved by cutting unspecified government spending, huge revenue increases to be achieved by closing unspecified tax loopholes. It was a con job all the way.
So how did Mr. Ryan reach a position where his actions may reshape the lives of so many of his fellow citizens, in most cases very much for the worse? The answer lies in the impenetrable gullibility of his base. No, not his constituents: the news media, who made him what he is.
You see, until very recently both news coverage and political punditry were dominated by the convention of “balance.” This meant, in particular, that when it came to policy debates one was always supposed to present both sides as having equally well-founded arguments. And this in turn meant that it was necessary to point to serious, honest, knowledgeable proponents of conservative positions.
Enter Mr. Ryan, who isn’t actually a serious, honest policy expert, but plays one on TV. He rolls up his sleeves! He uses PowerPoint! He must be the real deal! So that became the media’s narrative. And media adulation, more than anything else, propelled him to his current position.
Now, however, the flimflam has hit a wall. Mr. Ryan used to be able to game the Congressional Budget Office, getting it to produce reports that looked to the unwary like proper scores of his plans, but weren’t. This time, however, he couldn’t pull it off: The C.B.O. told the devastating truth about his plan, and his evasions and lies were too obvious to ignore.
There’s an important lesson here, and it’s not just about health care or Mr. Ryan; it’s about the destructive effects of false symmetry in reporting at a time of vast asymmetry in reality.
This false symmetry — downplaying the awfulness of some candidates, vastly exaggerating the flaws of their opponents — isn’t the only reason America is in the mess it’s in. But it’s an important part of the story. And now we’re all about to pay the price.
Your guide to the most contentious parts of the GOP health-care plan
by Robert Gebelhoff - Washington Post - March 24, 2017
The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)
Is the Republican health-care plan a return to freedom or a watered-down version of Obamacare? Will Republicans placate their base with a major legislative achievement, or will this be the party’s undoing for a generation of voters?
We’ve published the most incisive arguments from health experts and our columnists in the two weeks since Republicans unveiled this bill. As the debate reaches a climax, we’re giving you a guide to that commentary — pro and con, divided by subject matter:
- Eliminating health insurance mandates
- Age-adjusted tax credits
- Tax cuts
- The essential benefits package
- What’s the GOP’s end-game?
Eliminating health insurance mandates:
Conservatives have long argued that the Affordable Care Act’s requirement to buy health insurance is an affront to freedom — both for individuals and employers. They plan to replace these mandates with a penalty — paid to insurance companies, not the government — for people who buy insurance after a lapse in coverage of more than 63 days.
Here’s Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office: “The [GOP bill] places trust in the decisions of individuals and families by making greater use of health savings accounts (which hone the market incentives for higher-value care) and respecting their ability to follow incentives to be continuously insured.”
Critics are not convinced. The mandates exist to encourage healthy and younger people to buy into the insurance system. Without them, people would only buy insurance as soon as they are sick, and no one would pay the premiums that keep insurance profitable — causing an insurance market “death spiral.”
Here’s Timothy Jost of Washington and Lee University School of Law: “Paradoxically, this [insurance] penalty may discourage a healthy uninsured person from applying after a coverage lapse, but not someone in ill health who really needs insurance — and who will cost the system more.”
Age-adjusted tax credits:
To attract young people into insurance markets, the Republicans scrap subsidies and tax credits targeted toward low- and middle-income people. Instead, they want age-based systems that give older people larger tax credits than younger people. But the bill also lets insurance companies charge older people at a higher rate (five times more than younger enrollees, up from three times more under the ACA).
The CBO projects that this change would attract a sufficient number of younger, healthy people into individual health-care markets to lower premiums in the long run. But it does so by “substantially raising premiums for older people.”
Conservatives, like Charles Krauthammer, say this is fair:
Premiums better reflecting risk constitute a major restoration of rationality. Under Obamacare, the young were unwilling to be swindled and refused to sign up. Without their support, the whole system is thus headed into a death spiral of looming insolvency. Rationality, however, has a price. … GOP hard-liners must accept that Americans have become accustomed to some new health-care benefits.
Opponents worry this puts low-income elderly people at risk. There are also concerns whether the tax credits that are available would be enough to offset costs in places where care is expensive — particularly rural areas.
Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, argued that this structure would inherently destabilize markets:
The ACA pegs tax credits to income levels and, when premiums rise, those tax credits rise along with them, protecting consumers against regional differences and sudden increases in medical costs. But take those protections away, as the new bill would, and something perverse but entirely predictable happens: Sicker people keep paying (if they can), healthy people do not, and costs go up. That’s not partisanship but simple math.
Conservative critics worry that placing so much of a burden on the elderly would become toxic for Republicans, given older Americans’ voting power. Hugh Hewitt suggests fixing this by tying tax credits to both income and age:
Think of a square divided into four boxes: People are either poor or not poor, old or not old. Under the current bill, the credits are weighted too much toward the “young and not poor.” Instead, the tax credits should be disproportionately aimed at the “poor and old” box and after that the “poor and young” box. Then perhaps some small slice of the credits can be for “the old and not poor” with none for “the young and not poor.”
This is perhaps the most important part of the GOP plan for conservatives. Overall, the CBO projects that the bill would cut Medicaid spending by $880 billion over 10 years, resulting in 14 million fewer enrollees.
This is why supporters of the bill regularly characterize it as the first major repudiation of a government entitlement program in history. Avik Roy, president of the Foundation for Research on Equal Opportunity, describes the plan as “akin to the 1996 welfare reform bill times 10.”
Other supporters see this as a chance to keep Medicaid spending from growing out of control. The program has long been seen as a looming budgetary disaster, especially for states. Robert Samuelson covers this issue:
Slowly, Medicaid is usurping state priorities. Medicaid now claims nearly one-fifth of states’ general revenues, reports Robin Rudowitz of the Kaiser Family Foundation. Under present law, the squeeze will worsen.
Medicaid costs are split between federal and state governments — with the federal government agreeing to pay a certain percentage of the cost (varying by state). Republicans propose changing that structure by capping the amount of federal spending based on the number of people in the state. This, they hope, will prevent states from expanding the program.
Opponents of the bills say this would be a disaster. Here’s Andy Slavitt on that point:
In my time overseeing the government agency that runs [Medicaid], we dealt with many unexpected shocks — Zika, high-cost drugs and the national opioid epidemic, to name a few. Under the changes sought by Republicans, states would no longer have the resources to manage these crises.
Republicans often argue that the bill would only prevent Medicaid from growing further, protecting coverage for people who gained coverage under the ACA’s Medicaid expansion, so long as they have no lapse in coverage greater than 63 days.
But Benjamin Sommers explains that the legislation is designed to silently undo the Medicaid expansion:
People frequently move in and out of coverage, a phenomenon often called “churning.” Eligibility for Medicaid fluctuates with job losses or new employment, seasonal work or overtime, changes in family circumstances such as marriage or divorce and other factors.
So, for better or worse, this is where the rubber hits the road ideologically. Do we support government intervention in the market for low-income Americans, or not?
Freedom Caucus Republicans already shepherded an amendment allowing states to implement work requirements for Medicaid benefits. They would also give states the option to accept a lump sum of federal funds instead of the per-capita payments. This might be the closest they get to block grants for Medicaid.
Some of the fiercest criticism highlights how much high-income earners benefit from the bill. The GOP plan would repeal taxes on the wealthy imposed by the ACA to fund increased coverage, including a 3.8 percent tax on investment income and a 0.9 percent tax on people in the highest income brackets.
According to the CBO, the bill takes $1.2 trillion out of helping people get health care (including $880 billion from Medicaid) and then hands out about $600 billion of that in tax cuts, mostly for the well-to-do and various interest groups, the beleaguered tanning industry being my favorite. This could also be called the Make Inequality Worse Act of 2017.
And here’s Catherine Rampell on why these tax cuts are essential to the Republican’s plan:
The presence of expensive tax cuts in a bill purportedly about health-care reform is not a side effect; it’s the entire point. They make it easier for Republicans’ (much bigger) individual and corporate tax cuts to sail through the Senate with minimal Democratic obstruction in a few months’ time. Why? … Republicans can take the filibuster option away by using the “reconciliation” process, which is an option if, and only if, the tax bill doesn’t increase government deficits in the long term, relative to existing law.
Of course, these tax cuts are funded primarily by cutting Medicaid spending, so it’s an easy target for liberals to make the case that Republicans are filling the coffers of the rich off the backs of the poor (a.k.a., a reverse Robin Hood tax).
The GOP plan does preserve one particular tax that mostly affects the wealthy, and that’s the one on so-called Cadillac insurance plans — or expensive plans often available to high-income employees. The ACA was originally supposed to tax these plans at 40 percent starting in 2018 but delayed implementation until 2020. The GOP plan pushes that date back again to 2025.
Still, preserving the “Cadillac tax” attracted criticism from Republicans such as Sen. Rand Paul (Ky.), who characterizes the bill as “Obamacare Lite.” Avik Roy defends the GOP bill:
Rhetorically, GOP hard-liners such as Paul claim that they are implacably opposed to federal subsidies for health insurance, that they’re taking a brave stand against big government. Operationally, however, they support subsidies for the rich, and only oppose subsidies for the poor and the sick. That comes across not as a principled stand against statism, but as a political stand against Americans whose votes they don’t need.
The essential benefits package:
This is a policy item that got some last-minute attention to woo votes from conservatives opposing the bill. When the ACA was passed, it required insurers to provide “essential benefits” in 10 areas — such as mental health, dental and vision care for kids and maternity care.
For procedural reasons, the original bill preserved these requirements — Greg Sargent explains in depth here — but that didn’t sit well with Freedom Caucus members. So GOP leadership changed its view.
What would stripping out these benefits mean? Free market-minded people say that it would remove “paternalistic” government overreach. But others are concerned that health insurance wouldn’t do any good if it doesn’t cover basic needs.
What’s the GOP’s end game?
The goal of this bill is clearly to reduce the footprint of the federal government in health — pulling back Medicaid and adding market-based reforms.
But it’s hard to identify a fully formed Republican strategy since so many people within the party’s own ranks dislike the bill, as Dana Milbank notes. Plenty of critics argue that this entire episode illustrates how the Republicans never had a fully formed replacement plan in mind. Here’s Charles Lane:
After vilifying that set of interlocking policy compromises as a budget-busting, freedom-destroying ticket to second-rate medical care, the leaders of the GOP House have now declared, in writing, that they don’t have a fundamentally different idea, much less a better one.
Of course, Republicans aren’t able to draft their ideal plan because they’re trying to pass this plan through reconciliation — which means that this is technically a budget bill and can avoid a filibuster. That severely limits what they can put in the bill, such as a provision allowing consumers to buy insurance across state lines.
But more cynical critics believe that hard-line Republicans opposing the bill simply want the ACA to fail on its own without repealing it, even if that means actively taking steps to weaken President Barack Obama’s signature achievement. Here’s Greg Sargent’s analysis:
[It’s] not crazy to imagine that conservatives might prefer for the current repeal effort to fail, at least in its current form. … And needless to say, if it does fail, and the ACA lives on, conservatives can continue to say it’s a horrific failure — no matter what actually happens — thus proving them right about the folly of government efforts to expand coverage.
Conservative pundits such as Hugh Hewitt warn that such a failure to pass a health-care bill would mean the death of Republican majorities. But others, such as Jennifer Rubin, argue that it would be more disastrous for the GOP to put out a bill that would ultimately damage health-care coverage gains. Who is right is anyone’s guess.
If Health Bill Is Killed in the House, Ideology
by Nate Cohn - NYT - March 22, 2017
The bill to replace Obamacare is struggling to gain support from House Republicans, but not necessarily because of how the plan would affect their constituents.
Millions could lose insurance coverage under the Republican plan, particularly people in the states that expanded Medicaid under Obamacare, or the older, rural and low-income Americans who would receive fewer tax credits. Those issues have driven much of the Republican opposition in the Senate, where the bill is thought to have limited support.
But so far, the House Republicans who oppose the plan aren’t from the places most dependent on Medicaid or the Obamacare tax credits. They’re not even among the most vulnerable Republicans when considering the 2018 elections.
Instead, the health care debate is splitting House Republicans along ideological lines, with few signs that members are being pulled off familiar terrain by the effect of the law on their states or districts.
This could change before the Republicans bring their plan to a vote on Thursday. A disproportionate share of undecided Republicans are from Medicaid expansion states or relatively moderate districts.
But by Wednesday morning, 27 Republicans had publicly indicated that they would vote against the plan, according to NBC News — more than the 21 defectors that House Speaker Paul Ryan can afford to lose. It’s clear that ideological considerations, not whether their constituents are more or less vulnerable to the Republican plan, is driving the opposition to the bill.
Take Medicaid expansion. So far, 12 percent of Republicans from Medicaid expansion states are poised to vote “no.” For the states that haven’t expanded Medicaid? Also 12 percent.
What about rural districts, or states where the Republican plan offers far fewer tax credits than the Affordable Care Act, like Alaska? Same story.
Electoral vulnerability doesn’t seem to be a major factor either. So far, there are just three apparent “no” votes out of the 24 Republicans who represent districts carried by Hillary Clinton. By that measure, endangered Republicans are slightly more likely to oppose the plan, but most of the opposition still comes from Republicans who don’t have to worry about the general election.
Over all, 15 percent of Republicans who have less than an 80 percent chance of winning re-election (by our estimates) oppose the bill. In comparison, 12 percent of those with a greater than 95 percent chance of winning are opposed.
What do the opponents of the House bill seem to have in common? They represent competing ideological factions with predictable reservations about the Republican plan, regardless of whether their districts or constituents are posed to be disproportionately affected.
The members of the House Freedom Caucus, a group of conservative lawmakers that helped expel John Boehner as Speaker, are by far the likeliest to oppose the Republican bill. So far, more than half of Freedom Caucus members have announced their opposition, preferring a full repeal of Obamacare. They represent half of the current opposition to the bill, and more could follow.
Just 4 percent of Republicans who aren’t members of the Freedom Caucus oppose the bill. Those members tend to be ideologically moderate by most measures — although there is a small number of conservative, non-Freedom Caucus members who oppose the bill.
There’s a lot of overlap between relatively moderate Republicans and those who might consider themselves vulnerable to re-election. And it’s more than just overlap: The Republicans who would be likeliest to vote differently as a result of their electoral vulnerabilities would also be likeliest to have already amassed a moderate voting record. So far, both electoral vulnerability and past vote record seem to matter, but whether members have been moderate in the past has been a more powerful predictor of opposition.
These patterns could change by the time voting starts. Right now, vulnerable Republicans or those who represent Medicaid expansion states are much less likely to have publicly committed to vote for the bill, even though they’re not much more likely to oppose the bill.
Just 27 percent of representatives who have less than an 80 percent chance of winning re-election in 2018 (by our estimates) have publicly committed to vote for the law, compared with 48 percent of those who have greater than a 95 percent chance of winning. Similarly, 40 percent of representatives from Medicaid expansion states have said they support the bill, compared with 47 percent of those from non-expansion states.
As for the members that Mr. Ryan is counting on, to get over the top, he’ll need to break through among the representatives driven by ideology.
ACA's repeal would cause tens of thousands of deaths, while single payer would save 20,000 more lives than ACA: AJPH editorial
Researchers: Peer-reviewed evidence points to deadly consequences of being uninsured
FOR IMMEDIATE RELEASE, March 22, 2017
Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, email@example.com
Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, firstname.lastname@example.org
Repealing the Affordable Care Act without replacing it, as some conservative hardliners are demanding, would cost a minimum of 37,127 lives over the next two years (14,528 in 2018 and 22,599 in 2019), and perhaps as many as four times that number, according to scientific studies summarized in an editorial in this week’s American Journal of Public Health.
The new analysis of the effect of widespread insurance loss is particularly relevant in light of the report issued March 13 by the Congressional Budget Office. The CBO estimates that the American Health Care Act, the Republican plan to replace the ACA, would cause 14 million people to lose insurance in the first year alone. By 2026, 24 million would lose coverage, leading to a total of 52 million uninsured in that year.
In contrast, the editorial’s authors estimate the impact of replacing the ACA with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.
Longtime health system researchers Drs. David U. Himmelstein and Steffie Woolhandler analyzed all of the peer-reviewed studies of mortality associated with losing or gaining insurance. Using the CBO estimates of how many people currently lack insurance and how many more would lose coverage if the ACA were repealed without replacement, they provide a range of estimates of the excess deaths or lives saved under different health reform options (see table below). The evidence indicates that one American dies for every 300 to 1,239 who go without health insurance.
(See full Himmelstein and Woolhandler editorial for details on methods and sources.)
“The ACA extended coverage to 20 million Americans. But it offered little help to 90 percent of the population, including the 26 million who remain uninsured and millions more with unaffordable copayments and deductibles,” said study co-author Dr. Woolhandler, an internist, professor of public health at the City University of New York at Hunter College (CUNY), lecturer in medicine at Harvard Medical School. “Clear evidence tells us that fixing these defects would save thousands of lives. But Republicans’ plans would move us backwards.”
Dr. Himmelstein, the lead author of the editorial, a primary care doctor and, like Woolhander, a professor at CUNY’s Hunter College and lecturer at Harvard Medical School, added, “The Republican plan to replace the ACA would leave 52 million people uninsured in 2026. We know that will lead to many deaths – at least 41,969 and perhaps many times that number.”
Drs. Woolhandler and Himmelstein authored one of the early studies of the lethal effects of lacking health insurance, which President Obama cited in his push for the ACA. They, together with then-Harvard law professor Elizabeth Warren, led widely cited studies of medical bankruptcy.
The only way to end inequality in American health care is universal coverage
by Timothy Burns - Bangor Daily News - March 23, 2017
House Republicans, Deeply Divided, Face Painful Choice on Health Vote
by Jennifer Steinhauer - NYT - March 22, 2017
WASHINGTON — For the House Republicans who have never served under a Republican president — roughly two-thirds of them — the vote scheduled for Thursday on a measure to replace President Barack Obama’s health care law is a legislative fantasia, the culmination of seven years of campaign promises impeded by Mr. Obama’s veto pen.
But weeks of back-room machinations to bring a disparate group of lawmakers on board have left many Republicans with an excruciating choice: Pass a bill with an extremely limited constituency that could well wreak havoc with their own voters, and with Republicans’ re-election prospects, or vote it down, undermining President Trump’s agenda.
Speaker Paul D. Ryan said Wednesday that he was confident the House would pass the bill. But as of late Wednesday, roughly 30 Republicans had said they either would vote against the measure or had not made up their minds. That left the bill’s sponsors short of the 216 votes needed, and on Wednesday night Mr. Ryan scheduled a meeting in the Capitol to try to win over skeptics.
If House Republicans reject the measure, the working relationship between the White House and Republican leaders in Congress, still in its infancy, will suffer a powerful blow. In Washington, failure often begets more failure, as opposition forces strengthen, alliances fragment and the thin foam of bipartisanship evaporates.
“How do we have any momentum to do anything else?” asked Representative Richard Hudson, Republican of North Carolina. “Without this bill, I don’t know how you do tax reform,” he said. If the bill fails, “it’s going to have negative repercussions for all of us.”
Mr. Trump, a man who rushes to hang his name in gold anywhere he can, has rejected the nickname that some have given the House bill: Trumpcare.
But he has begun a last-minute campaign to both sweet talk and vaguely threaten fellow Republicans into supporting the leadership’s hastily written bill, though the measure, which would replace the Affordable Care Act’s health insurance mandate and generous subsidies with tax credits to buy insurance, has been criticized by the right and the left.
Mr. Trump met with a group of the most conservative House members at the White House on Wednesday, and Republican leaders are depending on him to finish the job. Indeed, this week many Republicans have begun to acquiesce to his and the House leadership’s desires, accepting that the bill, however flawed, is the best they are going to get.
At least for now, though, too many have not.
“The bill maintains Obamacare’s overall structure and approach, an approach that cements the federal government’s role in health insurance,” said Representative Rick Crawford, Republican of Arkansas, an opponent of the bill who represents the concerns of the conservatives.
Other more moderate members expressed opposite objections. “Under the current proposal, many South Jersey residents would be left with financial hardship or without the coverage they now receive,” said Representative Frank A. LoBiondo, Republican of New Jersey. “Our seniors on Medicare already struggle to make each dollar stretch.”
Some Republican leaders and those charged with drumming up votes suspect that some of the more conservative members are simply trying to force Mr. Ryan to cancel a vote on the bill so they do not have to go on record against Mr. Trump. But moderates may feel the pressure of voters: Large protests against the bill are planned for Thursday.
Further hampering them, House Republicans failed to do the grueling work of building a coalition outside Washington as Democrats did with the Affordable Care Act in 2009. While anti-abortion groups have warmly embraced the bill, which could restrict coverage of the procedure, it lacks other advocates. Doctors, nurses and hospitals have come out strongly against the measure, and insurance companies have been largely skeptical.Even if Mr. Ryan manages to secure the bare minimum of votes required, the bill that would pass the House would not become law. The Senate expects to make significant changes in the legislation, dragging out the process deep into the spring, if it can pass any version at all.
Senate Republicans, largely those from states that chose to expand their Medicaidprograms under the Affordable Care Act, so far have not seemed susceptible to pressure from leaders and Mr. Trump, listening instead to governors and constituents concerned about significant reductions in benefits.
Part of the bill’s problem is time itself. Much has changed in the years since the Affordable Care Act passed, with millions of Americans, many in red states, now getting health insurance as a result of the law, as well as treatment for the prescription drug addictions that have plagued scores of communities.
“My goal for this whole process was to help the people the law harmed and not harm the people it helps,” said Representative Dan Donovan, Republican of New York. At the same time, a fair number of conservatives would like to see those benefits greatly reduced, the central tension of the Republican debate.
As a result, it remains difficult to imagine a bill that could find its way out of the Capitol to Mr. Trump’s desk, given the broad disparities in what Republicans now seek.
Even if they can come together, House Republicans risk making the same mistakes Democrats made in the beginning of Mr. Obama’s term, when they pushed through what came to be known as Obamacare. That achievement, monumental at the time, ended up dragging down a once formidable Democratic majority and reducing the ability of Democrats to pass more legislation during his presidency.
Yet if the bill fails, Republicans in the House could end up like House Democrats under President Bill Clinton, who passed a controversial energy tax that was reduced to rubble in the Senate, but remained an albatross for Democrats in the 1994 elections.
The Democratic majority repeated that error in the early years of the Obama administration when the House passed a highly unpopular bill to cap the carbon emissions that cause climate change, only to see it go nowhere in the Senate, bringing down some House Democrats in the process.
Republican leaders are privately telling members that they do not want to be tarred as Republicans who voted with Democrats to maintain the Affordable Care Act. It’s a message they expect to resonate once the bill reaches the Senate.
“We remain committed to the repeal and replacement of Obamacare with policies that actually work,” Senator Mitch McConnell of Kentucky, the Republican leader, said on the Senate floor Wednesday as he urged members to get on board. “Americans are ready for a better way forward after the failure of Obamacare.”
But the flaw in that theory is that plenty of groups that usually support Republicans have already expressed distaste for the repeal-and-replace measure and are urging members to reject it.
“In 2018, members are going to have to campaign for re-election and say, ‘Look we repealed Obamacare,’ and voters are going to look at their premiums and say, ‘Oh no you didn’t,’ ” said Dan Holler, a spokesman for Heritage Action for America, a conservative group. “In the long term, it is not in the best interest of the Republican Party to pass this bill.”
House Republicans could console themselves in thinking that the vote on Thursday could be more like the excruciating vote in 2003 for President George W. Bush’s Medicare prescription drug benefit.
Then, House Republican leaders had to keep the vote open for hours as they twisted arms, finally securing passage, 216-215, over the opposition of the party’s most conservative members, including the current vice president, Mike Pence, an Indiana congressman at the time.
But that measure, which did become law, has proved popular and durable, and the vote — which led to ethics charges against some of the arm-twisters — has largely receded into the history books.