In March, House Republicans tried to pass a health-care bill that slashed Medicaid by $880 billion to finance a tax cut for the rich; radically increased the cost of insurance for old people in rural America (a.k.a., the Republican base), so as to make it slightly cheaper for upper-middle-class young people in cities (a.k.a., the Democratic base); and established a system of subsidies for insurance so poorly designed it would have actually left more people uninsured than if you eliminated the entire Medicaid expansion — and every other part of Obamacare — and replaced it with nothing at all.
These ideas proved so unpopular with non-millionaire voters and health-care-industry stakeholders that the House’s GOP moderate wing had enough votes to kill the bill, even without the help of the Freedom Caucus conservative purists for whom it wasn’t punitive enough.
Six weeks later, House Republicans tweaked their bill to allow states to waive the requirement that health insurers cover preexisting conditions and put a fig-leaf amount of backup funding over the massive increase in health-care costs for, say, nonaffluent cancer patients that would ensue. The bill’s most regressive aspects were left almost entirely in place. And on Thursday, Trumpcare passed the House with a vote to spare.
Here are seven reasons Republicans were able to make that happen.
1. Donald Trump made Reince Priebus’s life a living hell.
The president is not an artful deal-maker. Trump lacks a remedial understanding of health-care policy, legislative procedure, or the ideological disputes within his own party. He is also a deeply lazy man whose favorite (only?) negotiating tactic is to make extraordinary ultimatums — and then back down at the first sign of resistance.
It’s not surprising then that GOP insiders are (anonymously) downplaying Trump’s role in yesterday’s victory. And it’s true that Trump contributed far less to yesterday’s win than did a handful of key players in Congress. But it’s still hard to dismiss the notion that the House vote was, in part, a triumph of Trump’s will.
The president may not be invested in the details of health-care reform. But he is deeply invested in being perceived as a winner. So, when Trumpcare’s failure produced a flood of headlines suggesting the very opposite, Trump’s wounded ego took out its rage on the White House chief of staff.
Trump took to mocking Reince Priebus for his “too-cozy” relationship with Speaker Paul Ryan, “merging the two men’s names into one long ‘Ryan-ce,’” and reminding Reince of his health-care failure whenever the obsessive-compulsive Wisconsinite stood idle, as the New York Times reports:
In recent days, Mr. Priebus cut back on his stalking-butler tendency to hover over the president, realizing his antsy boss had grown resentful of his constant companionship. “What are you doing in here? Don’t you have health care to take care of?” Mr. Trump asked Mr. Priebus at one recent meeting around his desk, according to a senior White House official.
Priebus responded to this bullying — and the omnipresent murmurs than another health-care failure would be his doom — by ringing House Republicans’ phones with all the manic persistence of a newly jilted ex-lover. Politico offers details on Ryan-ce’s relentlessness.
When the MacArthur-Meadows deal looked close to being done, Priebus called a White House meeting with Ryan and asked him to cancel a looming two-week congressional recess in order to finish the bill…“There will be calls for you to resign,” Priebus told Ryan, according to two people in the room. (Another source familiar with the conversation but not in the room said Priebus’ comments were not aimed at Ryan but at Republicans in general.)
… Priebus’ hounding didn’t stop there, though. In the days before the bill finally passed, he began calling members listed as “no” votes and asking them what they needed to get to yes — whether on health care or other things the administration might be able to do for them.
House GOP sources were eager to paint Priebus’s efforts as irrelevant or counterproductive. But given the myriad reasons to believe that Trumpcare was better off dead — not least the immense liability the bill’s revival posed to vulnerable Republican House members — Priebus’s drive to save his own job by any means necessary probably played a part in forcing Thursday’s vote.
2. Tom MacArthur decided to spend his beach vacation helping the far right produce a politically tenable plan to make health-care unaffordable for people with preexisting conditions.
Trumpcare’s revival began with negotiations between Mark Meadows of the Freedom Caucus and Tom MacArthur of the moderate Tuesday Group. The purpose of these talks was difficult for outside observers to comprehend. After all, Trumpcare had been too moderate for Meadows’s team and too right-wing for MacArthur’s. There simply was not any happy middle ground between their two positions.
But what outside observers missed was that the Tuesday Group was, itself, a bunch of outside observers. Acting against the wishes of the moderates he ostensibly represented, MacArthur helped the House’s reactionaries make their deeply unpopular plans more politically tenable through the magic of federalism — and then allowed them to brand the resulting proposal as a magnanimous compromise.
The day after Trumpcare failed, MacArthur “couldn’t stop thinking about how close conservatives and GOP leaders had come to an agreement at a late-night meeting with Vice President Mike Pence a few days earlier,” according to Politico.
And so, during a beach vacation with his family over the Easter recess, MacArthur sketched out a plan to allow states to choose to nullify two of Obamacare’s most popular provisions — protections for people with preexisting conditions, and regulations requiring all health insurers to cover a set of basic services, including mental-health and maternity care.
The resulting amendment did not make the health-care bill any more appealing to moderates. But the fact that it was drafted by a self-identified centrist made it more politically difficult for the House’s other “squishes” to maintain the courage of their convictions.
3. Fred Upton got moderates the Michigan Morsel.
If only one self-styled “reasonable Republican” agreed to put lipstick on the far-right’s pig, that swine might still have been slaughtered. MacArthur’s amendment may have marginalized the other moderates, but as of early this week, the Tuesday Group seemed more in the mood for excommunicating its turncoat than accepting Trumpcare 2.0.
And then Fred Upton debuted the year’s most effective bit of political theater. The Michigan representative was known as a reliable vote for the GOP’s leadership — one who had been instrumental in getting the original health-care bill out of committee. So, when Upton declared his opposition to the new bill Tuesday morning, Trumpcare was once again pronounced dead.
But this climactic crisis only served to heighten the catharsis of the House GOP’s happy ending. On Wednesday morning, the president and Upton agreed on a game-changing compromise: The new bill would set aside $8 billion — over five years — to fund high-risk pools for people with preexisting conditions in states that opted to abolish their protections.
As with the MacArthur Amendment, this proposal didn’t actually offer moderates anything of substance. The conservative American Enterprise Institute estimates that such high-risk pools can only be maintained with outlays of $15 to $20 billion a year. And the bill already included a $130 billion slush fund for states to use to ameliorate various problems the legislation might create.
But if the Michigan Morsel changed nothing substantively, it did change things politically, creating a sense of “momentum” that House moderates proved ill-equipped to resist.
4. Mike Pence has credibility with the Koch brothers.
One of the many obstacles to Trumpcare’s passage in March was the opposition of conservative outside groups. The White House may not have won over any of the health-care sector’s actual stakeholders, but the vice-president was able to sell the new bill to the far-right-funding billionaires.
“The framework for a deal began when Pence doggedly worked the phones and scheduled meetings to explain the provision [allowing states to opt out of Obamacare rules] to outside groups,” Tim Phillips, president of the Koch-backed Americans for Prosperity, told Politico. “It needed to be someone really credible since there was no language, and that was him.”
5. Obamacare is not working well in Iowa.
The last insurer on Iowa’s exchange pulled out the day before the vote, leaving thousands without an option to purchase insurance.
That troubled Rep. David Young (R-Iowa.), who had remained opposed to the measure throughout the talks. The vulnerable Republican felt compelled to vote for a replacement in light of his home-state situation. In a meeting with Ryan, McCarthy and Scalise just hours before the vote, he delivered them the news.
6. The anti-Trump resistance scared the hell out of the House GOP.
Many observers interpreted Thursday’s vote as a testament to the progressive movement’s fatigue — but ironically, it may have actually been a reaction to the resistance’s vitality. As the Washington Post reports:
As GOP leaders scrambled to bring the last holdouts aboard in recent days, they made the argument that the liberal base is already on fire, anxious to take back control of the House in next year’s midterm elections. That means Republicans could ill afford to fall short on their health-care promise and risk depressing their own turnout.
It may have been political suicide for vulnerable House Republicans to vote for this monstrosity. But in era of hyperpolarization — where elections are often determined by mobilization, not persuasion — many embattled GOP incumbents decided they’d rather risk alienating the middle than disappointing the conservative base. If Trumpcare dies in the Senate, this may prove to be a decent bet.
7. The House’s Republican moderates lack an independent donor base, and a spine.
When they could share the blame for Trumpcare’s failure with their party’s far-right fringe, House moderates were happy to put the interests of their constituents above the president’s self-esteem. But once the Freedom Caucus and Tom MacArthur conspired to isolate them, many sacrificed their most vulnerable voters to give Trump his desired photo op.
Whatever political pressures were marshaled against them, they did not have to do this. America is not (yet) an authoritarian country. Trump would have punished dissenters with angry tweets, not a breakfast of polonium. Anyone who understood the cruelty of the bill one month ago but voted for it yesterday is a repulsive coward.
But as Vox’s Matt Yglesias notes, the power structures of the American right make moderate Republicans ripe for repulsive cowardice:
Moderate Democrats have a separate — and oftentimes larger — donor base than progressive ones, drawn from the ranks of lobbyists and others in the business community. Moderate Republicans fish in the same big-money ponds as their more conservative colleagues, but the conservatives can also fall back on grassroots donors whom the moderates don’t have.
The moderates’ distinct value-add is they will reliably deliver “yes” votes for bipartisan deals the GOP leadership makes that the base doesn’t like. That earns them brownie points from leaders and moderation points from less conservative voters. But they don’t have a separate institutional leg to stand on in order to fight against the party leadership.
The Freedom Caucus, by contrast, has a distinct base of donors among grassroots activists and eccentric far-right billionaires.
In other words, Trumpcare passed the House for the same reason Trump became president and the Earth is fast-becoming unfit for human civilization: Politicians are more afraid of libertarian billionaires than an actual populist revolt.