Fractured Republicans face pitfalls on the road to Obamacare repeal

http://www.politico.com/story/2017/03/republicans-obamacare-repeal-pitfalls-235791

Congressional Republicans rolled out their Obamacare repeal and replace plan – and landed in a minefield. Republicans have been promising for seven years to get rid of the health law – and now that they have control of the House, Senate and White House, their voters expect them to do just that. But intransigent House conservatives, skittish moderates, an unpredictable new president, and a health industry wary of upending the status quo all stand in the way. If any single faction bails, it could sink the entire repeal effort. And they can’t expect help from the Democrats, who back the Affordable Care Act, and who see a health care debacle for the GOP as just what they need to rebound in the 2018 congressional elections – just like the GOP capitalized on the Obamacare backlash in 2010 to win their big House and later Senate majorities. Here are seven of the flashpoints that could sink GOP efforts to finally put an end to Obamacare.THE PRICE TAGHouse Republicans are kickstarting their health care overhaul in a vacuum. With no official estimate from the Congressional Budget Office, they have no idea yet how much their American Health Care Act costs and how many people might lose their health coverage because of it. Without knowing that bottom line, members may be reluctant to offer full-throated support. And if the CBO numbers are ugly, they could send critics to even higher decibel levels.Republicans spent years trashing the Democrats’ health care law as a budget buster (even though the CBO didn’t agree) A bad CBO score for the GOP bill could undercut their claim to fiscal rectitude.REVOLT FROM THE RIGHTHouse Speaker Paul Ryan strode to a Capitol microphone Tuesday and predicted success. “We’ll have 218 [votes] when this thing comes to the floor, I can guarantee you that,” he declared. But here’s what he’s up against: Conservative activists and advocacy groups are out in force railing against the GOP’s opening bid. Lawmakers that make up the hard-right of the GOP caucus are building a wall of opposition against what they swiftly branded “Obamacare-lite” and they are particularly fired about the fact that the bill retains tax credits to subsidize insurance, although they are less money than Obamacare.President Donald Trump, Vice President Mike Pence and the House GOP Leadership joined to show support Tuesday. But without the hardball-playing Freedom Caucus on board, the odds the House can pass an Obamacare replacement plan are effectively nil. “There’s nothing ‘wonderful’ about GOP plan,” said Rep. Justin Amash (R-Mich.), needling Trump for his tweeted praise of the plan. “It repackages Obamacare, breaks promises and doesn’t lower costs.”SENATE MODERATES HOLDING OUTIf Republican leaders manage to usher the AHCA past angry House conservatives, their reward will likely be yet another intraparty roadblock – and an even slimmer margin for defections in the Senate. Several Senate Republicans – mostly, but not all, relatively moderate — have raised objections to the House’s approach, warning of the consequences of rolling back Obamacare’s Medicaid expansion or rushing legislation that could further damage the health insurance markets. On Monday, Sens. Cory Gardner, Shelley Moore Capito, Rob Portman and Lisa Murkowski all pledged to vote against any legislation that doesn’t protect coverage under Medicaid. Sens. Dean Heller, Bill Cassidy and Susan Collins have also expressed reservations, making for at least seven potential GOP Senate defectors.Republicans can only lose two votes in the Senate and still pass the repeal bill through a fast track process that requires a simple majority vote. The prospect of that tightrope already has party leaders treading carefully.UNPREDICTABLE DONALD TRUMPTrump is nominally in favor of the House’s health care framework. His top health aide, HHS Sec. Tom Price, said as much during a Tuesday press briefing. So did Vice President Mike Pence after meeting with lawmakers at the Capitol. But the president has startled lawmakers before with policy and rhetorical shifts, and he hasn’t fully embraced the House’s proposal yet. He tweeted praise but White House aides left wiggle room for the president to demand changes.Trump himself called the House rollout the beginning of a “review” and “negotiation.”The president has also managed to plunge his party into days of turmoil with stray tweets about Russia. Similar snafus wouldn’t just be distractions now that the repeal drive is underway; they’d be detrimental to the GOP policy agenda and message. (White House press secretary Sean Spicer on Tuesday couldn’t say whether Trump would commit to refrain from tweeting anew about unfounded accusations about former President Barack Obama wiretapping him.)And Trump hasn’t always spoken from the same messaging playbook as Republicans on health care, a fact he once wore proudly during his presidential primary fight.“You cannot let people die on the street, OK?” Trump said during a February 2016 primary forum. “Now, some people would say, ’that’s not a very Republican thing to say.’ … I said, you know, the problem is everybody thinks that you people, as Republicans, hate the concept of taking care of people that are really, really sick and are gonna die … That’s called heart. We gotta take care of people that can’t take care of themselves.” Watch how he responds if the CBO says millions would lose coverage.PUSHBACK FROM THE STATESThe push to overhaul Medicaid means the House bill could have to get past one more formidable group – the 16 Republican governors whose states are now benefiting from Obamacare’s Medicaid expansion. (Some Republican governors aren’t crazy about all the specifics of the plan to change traditional Medicaid from an open-ended entitlement into a fixed per capita payment either.)The concern about expansion has resonated among Senate Republicans, who have encouraged the governors to put together an alternate plan for restructuring Medicaid. That plan – which centers on ensuring expansion and non-expansion states are treated equally as federal Medicaid funding is limited – is still a work in progress. But it’s likely to be more generous than House conservatives prefer, creating another potential flashpoint between Republicans in the House and Senate.That danger was clear from the start. Ohio Gov. John Kasich, an early supporter of expanded Medicaid who fought his own GOP legislature to pass it, called the GOP’s designs on Medicaid "counterproductive" and urged Republicans and Democrats to craft a bipartisan solution.INDUSTRY GROUPS GETTING COLD FEETEarly returns are trickling in from the health care industry – and they aren’t happy. Health insurers and hospitals are each finding things to dislike in the repeal legislation. They’re panning its system of tax credits and raising alarms about the GOP’s Medicaid overhaul, warning the bill’s central provisions could lead to massive coverage losses. That means insurers would have fewer paying customers, and hospitals once again would have to foot the bill – either through more charity care or bad debt – when the newly uninsured show up in the emergency room. And these are deep-pocketed industries, with lots of local influence.“Our health plans now have some idea of what to expect with respect to policy down the pike,” Alliance of Community Health Plans CEO Ceci Connolly said, applauding the GOP’s success in finally proposing repeal legislation. “The content of the [GOP] bill is where there are some concerns.”The American Hospital Association, too, came out against the Republican bill in its current form.Republicans had largely downplayed the need for industry support early on, maintaining that health care companies would fall in line once they realize how much better the GOP health plan is compared with Obamacare. But that hasn’t happened yet. And health care groups are warning that unless the Republicans find a way to keep Obamacare’s coverage gains, it will be hard for them to get on board. 2018 POLITICSLooming over the entire repeal battle is the specter of massive electoral losses. Republicans recall the Tea Party wave that swept out Democrats over Obamacare in 2010; they know how explosive health care politics can be. They’ve already gotten a taste at the intense town halls last month, packed with protesters and constituents defending the health law.Obamacare has also enjoyed a boomlet of support as its survival has been threatened. Polls suggest more Americans would rather keep and repair the law than eliminate it. In addition, vulnerable GOP lawmakers are being asked to take an enormous risk at the direction of a president who himself is stuck underwater in many of their districts.Democrats need to pick up 25 seats to retake the House majority, almost the precise number of Republicans who sit in districts won by Hillary Clinton last November. Democrats, buoyed by fresh polling on Obamacare’s gradually climbing favorability, hope that tough votes on health care translate into positive political momentum.

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