President Donald Trump may be hands-off when it comes to health policy, but the task of corralling Republicans is right up his alley. His work to close the deal on the GOP bill to repeal Obamacare harks back his days as a developer who mixed hyperbole with weighty-sounding promises and/or threats to get what he wanted.
The sprawling amendment GOP leaders unveiled Monday night in a bid to win over wavering Republicans contained gifts for wary moderates and unruly conservatives, all wrapped in bare-knuckle rhetoric. The promise is big rewards or punishments — choose your own ending. But it’s still too soon to know whether Trump, who craves drama as much as he loves to look like a winner, comes out on top when the House votes Thursday.
Call it the art of the health care deal.
Here’s a look at five key elements:
1) Cover your back
The updated bill calls for additional tax credits for older Americans, which are meant to neutralize one of the most startling findings from last week’s CBO analysis — the dramatically higher costs projected for older people, a key Trump voting bloc. Poorer, older people were expected to be hit especially hard by the GOP health plan, thanks to far less generous aid and new insurance rules that would allow them to be charged five times more for coverage than younger people.
The boosted tax credits are aimed at winning over more persuadable moderates, who wanted reassurance that the funding preserves insurance for a few million additional people. GOP sources have pegged the cost of the increased aid at $85 billion.
Here’s the rub — the bill doesn’t actually include that pot of money. It instructs the Senate to build in the funding when that chamber gets to work on the measure. The idea was to give House conservatives who worry about spending a cleaner conscience, since they didn’t actually approve the funding. But a few conservatives in the House Freedom Caucus don’t sound as if they’re any happier.
2) Know when to buy off the opposition
Conservatives already were pleased with the how the repeal bill would end Medicaid as an open-ended entitlement and cap federal payments to states — a policy goal they’ve pursued for years. But the package of changes gives them even more, by allowing governors to impose work requirements on Medicaid recipients and letting states convert their Medicaid programs into block grants. Both were long-sought policy changes: The Obama administration had rebuffed states who sought approval for Medicaid work requirements.
Heritage Foundation welfare expert Robert Rector notes the work requirements are largely symbolic and somewhat ironic, coming after the GOP largely failed to attach similar conditions on cash, food and housing aid for more than a decade. Moreover, it might be politically dicey to enforce a work requirement on a sick person who appears in a clinic or hospital emergency room. The manager’s amendment would provide extra federal money to help states do so, possibly by enrolling the sick person prospectively in Medicaid, then requiring participation in a workfare program or job search at some point in the future.
The block grants also sync up with the conservative argument that states are better positioned than the federal government to help their low-income residents. Florida Gov. Rick Scott this week argued for that approach for his state’s $26 billion Medicaid program, as he pressed for relief from a federal requirement that Florida retroactively cover health care costs for new Medicaid beneficiaries, among other things.
3) Offer more sweeteners, aka the ‘Buffalo Bribe’
The package contains language brokered by Rep. Chris Collins (R-N.Y.) designed to win the support of his state’s GOP representatives. It would transfer more of the burden of caring for Medicaid beneficiaries from counties to the state. Currently, New York’s Medicaid program relies on contributions from the federal, state and counties — and Collins argues the burden is greater on counties than in other states.
The so-called Buffalo Bribe (Collins’s congressional district more or less circles that city.) continues the tradition of trying to manipulate Medicaid payment policies to buy off votes. During the bitter fight over Obamacare, ex-Sen. Ben Nelson (D-Neb.) carved out a deal that came to be known as the “Cornhusker Kickback,” in the form of a permanent exemption from the state share of Medicaid expansion for Nebraska. The New York language played well with the likes of Rep. Claudia Tenney who represents an upstate district, but got panned by Democratic Gov. Andrew Cuomo.
4) Let the holdouts know revenge is an option
Trump didn’t explicitly threaten House Republicans Tuesday he would work to unseat them if they opposed this bill, but his message seemed to contain a veiled warning.
“Many of you came in on the pledge to repeal and replace Obamacare,” Trump said. “I honestly think many of you will lose your seats in 2018 if you don’t get this done.”
Trump has made clear that setbacks on health care threatened to delay or derail the rest of his agenda on taxes and trade, for instance. And as he recently told Michigan’s Republican Gov. Rick Snyder, who didn’t endorse him during the campaign, he never forgets any slight.
At the same time, conservatives inclined to support Trump are facing competing pressure from an influential conservative group to oppose the repeal bill. Heritage Action and Club for Growth said the changes to the bill still don’t go far enough to repeal Obamacare.
5) Dangle something else before them
Trump has cast Thursday’s planned House vote on the repeal plan as precondition to moving onto other, bigger pieces of his agenda. At a rally in Louisville, Ky., Monday night, and in other appearances, he’s sounded more energized about taxes, trade, manufacturing and his “America First” foreign policy.
“We want a very big tax cut,” Trump said in Louisville, “but we cannot do that until we keep our promise to repeal and replace the disaster known as Obamacare.”
Trump also used the speech to circle back to drug prices — a potential carrot for the fence-sitters and a possible bipartisan rallying point in Congress. He repeated his pledge to bring the cost of prescription medicines “way, way, way down,” either by adding a drug-cost measure to the repeal bill or addressing the issue in subsequent legislation.
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