The White House and congressional Republicans are getting to the white-knuckle phase of a difficult effort to secure enough votes in the House to pass the American Health Care Act, their principal repeal-and-partially-replace-Obamacare legislation. Clearly lacking the support to get the unattractive measure across the line and over to the Senate in the vote pending Thursday, a “manager’s amendment” has been put together that incorporates sweeteners for various House factions — including conservatives wanting a tougher crackdown on Medicaid, centrists worried about the impact of a massive rise in premiums on near-retirees of limited means, and anti-abortion advocates demanding assurances that the final bill will not only defund Planned Parenthood, but make indirect subsidies for abortion and contraceptives impossible.
This all makes sense if the GOP is going to have any chance of salvaging legislation that conservatives in various camps are attacking for diametrically opposed and mutually exclusive reasons. But one sweetener that made it into the leadership package is very likely going to have ominous implications down the road: a special deal for New York counties (outside New York City). Here’s the New York Times’ description:
House Republican leaders, trying to lock down the votes of wavering upstate New York Republicans, inserted a last-minute special provision in their health-care bill that would shift Medicaid costs from New York’s counties to its state government.
The move — one of a number of late changes designed to gain more votes — would affect New York State only. It could save county governments outside of New York City $2.3 billion a year. But it could shift costs to state taxpayers or deny New York that same total in matching federal aid if the state continues to require those counties to contribute to the cost of Medicaid. Upstate New York Republicans, backed by local government officials, pressed for the measure over the angry opposition of New York’s Democratic governor, Andrew M. Cuomo.
There’s no real health-policy rationale for this deal, which will bring back memories of the infamous “Cornhusker Kickback,” the special treatment for Nebraska that was nestled into the Senate version of the Affordable Care Act to secure the vote of Senator Ben Nelson. (It was later removed from the final version of the ACA.) Indeed, the eight House members who will likely share credit for the deal secured by Representative Chris Collins are already touting it as intended to produce a local property-tax cut.
What makes this a lethal precedent is the likelihood that multiple senators will now find themselves under pressure to demand similar deals. What state doesn’t have taxes that might be cut if someone else can be found to pay for health-care services? Which senator does not have hungry special interests that could use a treat? And bad as the legislative situation is in the House, it will only take three Republican senators to sink the AHCA. With the administration and the congressional leadership already facing outspoken “concerns” from conservatives Rand Paul, Ted Cruz, and Mike Lee — along with opposition to anti-abortion provisions from Susan Collins and Lisa Murkowski — these and other Republican senators have set themselves up nicely to approach the bill’s sponsors for concessions large and small. In essence, the New York deal (let’s call it the “Empire State Shakedown”) rings a loud dinner bell for senators to “come and get it while it’s hot.”
You can see how this could quickly get out of hand. Yes, we can expect the bill’s backers to say the deal-making window is closed and the Senate must take it or leave it. But if they are hung at 48 or 49 Senate votes, such tough-sounding statements will melt away like the last of the winter snow on the first warm day. Worse yet, whatever abomination manages to get through the Senate will have to go through a House–Senate conference subject to even more deal-making, and then the final product will need to pass both houses.
Republicans are now paying the price for all those years of spreading demagoguery against Obamacare without spending some time figuring out a plan most of them could support. Now, the shakedown artists are in charge. We’ll find out if the supposed genius of Paul Ryan, the legendary legislative skills of Mitch McConnell, and, yes, the president’s “art of the deal” can, in combination, bring a poorly designed bill that’s losing shape every day to some sort of ghastly conclusion.