Why the GOP’s Senate Health-Care Bill Won’t Be Getting Much Nicer

Mitch McConnell will cut some deals on health care, but he has to watch his back on items conservatives won’t accept. Photo: Melina Mara/The Washington Post/Getty Images

Now that the “discussion draft” of the Senate version of the Affordable Health Care Act has been released, we are at the point in the legislative process where Mitch McConnell is going to open up the kitchen, ring the dinner bell, and ask what senators need to sign on. If and when he has 50 votes, he’ll close up shop and get the bill onto the floor as soon as possible.

As my colleague Jonathan Chait has explained, McConnell’s game will be to make the minimum number of concessions for the maximum political clout. This is particularly true with respect to the GOP “moderates” who have publicly or privately shared the president’s view that the bill is “mean” and needs some sweeteners for public opinion.  Aside from the need to keep his own restive hard-core conservatives on board, McConnell also has to constantly remember that the cannot stray too far from the House bill if he wants to get legislation onto Trump’s desk anytime soon. Indeed, the ideal outcome for Republicans would be a Senate bill the House could just accept, eliminating the need for a time-consuming and dangerous House-Senate conference and then another round of votes in both chambers.

So it’s in both McConnell’s interest and that of the “moderates” to whom he is making concessions to vastly exaggerate their significance. The perfect precedent was supplied in the House by Rep. Fred Upton, who created a huge stir by coming out against AHCA but then quickly climbed back on board (bringing another recalcitrant Member with him) in exchange for a really small concession on money for high-risk pools. You can expect similarly paltry “deals” in the Senate to be described by all concerned as equivalent in great-heartedness and civility to the Compromise of 1850 (except, of course, that they will all be within one party).

But at the same time, there are lines in the sand McConnell will not cross because they defend turf sacred to his and the House’s dominant conservative factions. Here’s an educated guess at what those lines might be:

Tax cuts must mostly stay.  While negotiators might offer some wiggle room on effective dates for the delay of the Obamacare tax repeal provisions in the bill (as they already have in no longer making them retroactive as the House bill did) to free up money for other concessions, they won’t go very far. There’s been virtually no objection among congressional Republicans to the tax cuts on the merits. For conservatives, they are central to the bill’s appeal, and help offset whatever misgivings they have about how far the legislation goes in scrapping Obamacare. It will also be important for McConnell to make it clear the tax money doesn’t represent a big pot o’ gold from which moderates can finance more generous benefits (though that’s exactly what it could be if senators chose to treat it that way).

The Medicaid expansion must go and and a permanent Medicaid per capita cap must be imposed. Again, negotiators might monkey around a bit with the formula for how rapidly the Obamacare Medicaid expansion is killed and how deeply the long-term Medicaid cap would bite. But a pretty quick end to the expansion, and a pretty devastating long-term cap, are non-negotiable for conservatives. In their minds the expansion took an already out-of-control “entitlement” program that subsidizes social pathology and extended it to a whole new population of able-bodied adults without kids. Rolling that rock down the hill and then pushing it in the opposite direction by eliminating Medicaid’s open-ended nature is one of the most important conservative policy goals in this entire exercise.

Private insurance premiums must stabilize or better yet come down. If liberals look at health care policy and tend to identify with poor people or those with preexisting health conditions, conservatives are more likely to identify with middle-class folk buying insurance on the individual market whose premiums have gone sharply up under Obamacare. There are various ways the House and Senate bills seek to lower these premiums, but probably the most important is the provision letting states waive Obamacare’s “essential health benefits” rules. Less extensive insurance (which many healthy people would prefer) means lower premiums. And lower premiums give Republicans a talking point to counter the bad statistics this bill or anything like it will generate in terms of people losing health insurance. Indeed, loosening requirements for the quality of insurance could lower the number of uninsured, too, though significantly boosting the ranks of the “underinsured.”

There can be no subsidies used to pay for abortions, directly or indirectly. This is probably the most non-negotiable principle for all but a very few Republicans. Anti-abortion activists will be more critical than ever to a Republican Party fighting to preserve its power in 2018. Right now they are quite happy with Donald J. Trump and the Republican Congress. That would change quickly if Congress passes and Trump signs a health care bill that crosses the RTL lobby. The clearest case involves the bill’s one-year ban on any federal dollars going to Planned Parenthood, the current Great Satan figure for anti-abortionists. If that goes out of the bill, the bill goes down, probably in the Senate, but surely in the House. There has been some talk that the Senate parliamentarian might rule the Planned Parenthood ban non-germane to the budget and thus non-allowable in this kind of bill, but that seems unlikely, since the same parliamentarian okayed similar language in a similar bill in 2015 (the so-called “trial run” repealing Obamacare, which Obama vetoed). Similarly, though three Senate Republicans have on occasion taken issue with the Planned Parenthood ban on the merits, only one—Susan Collins—is thought likely to make this issue a deal-breaker, and she may be lost on this legislation anyway.

The situation is dicier with a House provision that prohibits use of federal tax credits to buy private health insurance that includes abortion services. That language is still in the Senate bill, despite multiple reports the parliamentarian considers that emphatically non-germane. If that’s true (and we’ll probably find out for sure by the beginning of next week), then Senate leaders will probably try to talk RTL lobbyists into cutting them some slack so that the whole bill isn’t in danger of falling apart. But if that doesn’t work, I have no doubt McConnell and company will run the risk of creating a terrible precedent by overruling the parliamentarian and declaring the provision perfectly appropriate. For today’s Republicans, getting at cross-purposes with the RTL people is worse than violating sacred Senate rules and customs.

There is always a chance that if he’s hanging one vote shy of the 50 needed to pass this big, messy and unpopular bill, Mitch McConnell will do what has to be done and count on fixing any affronts to the above conservative sensibilities down the road. But in any dispute over congressional Republican priorities, it is generally a good idea to assume conservative ideology ranks first.

GOP’s Senate Health-Care Bill Won’t Be Getting Much Nicer