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One of the dominant political narratives of the past several years has been that the Republican Party is in thrall to its most conservative members. Tea party-backed legislators spurred a government shutdown in 2013 and two years later helped push out House Speaker John Boehner, whom they deemed excessively conciliatory to President Barack Obama. And now that their party controls all the levers of government, they aren’t letting up: Conservative members of the House, now known as the Freedom Caucus, effectively killed the first version of the American Health Care Act when they decided the bill to “repeal and replace” Obamacare didn’t go far enough.
From one perspective, Thursday’s narrow victory in the House for the revised AHCA is the ultimate demonstration of the Freedom Caucus’s power. The only reason the bill rose from the dead is that President Trump and Republican leaders in Congress gave in to the caucus’s demands in key policy areas. Most significantly, the new bill would let states opt out of many of the Affordable Care Act’s most significant requirements. (More about what the bill means for health care later in this column.)
But in another sense, Thursday’s vote also reflected the power of a different group: moderate Republicans. Earlier this week, the revised bill looked doomed, mostly because in acceding to the demands of conservatives, GOP leaders had made the bill unacceptable to moderates. (Democrats were almost certain to vote unanimously against any plausible version of the bill, as they did on Thursday.) Winning back enough moderate Republicans to get the bill through the House required another set of concessions (including $8 billion in new funding to support coverage for people with pre-existing conditions). And the House vote was just a preview for the coming battle in the Senate, where moderates wield far more influence.
It would be tough to describe the AHCA as a victory for moderates, or even moderate Republicans. (“Moderate” is a relative term in the GOP, of course. Today’s moderates, especially in the House, are very conservative by historical standards.) Even with that $8 billion, the new bill will significantly erode protections for people with pre-existing conditions, according to most analyses; it will also probably leave millions more Americans without health insurance.1 But moderates provided the key votes to getting the bill over the finish line, and while the concessions they exacted were modest — the final bill is still significantly more conservative than the previous version — they were a signal that no health care reform will become law without their support. In the Senate (and perhaps also in the eventual conference vote in the House), that could require shaving off some of the legislation’s sharpest edges.
Moderates, both in Congress and in the White House, have done a fair amount of edge shaving recently. Take this week’s budget deal, for example: Trump initially wanted Congress to provide money for his border wall and to block federal funds for so-called sanctuary cities. The final deal included neither of those provisions. (It also boosted funding for the National Institutes of Health, which Trump wanted to cut.)
Another example: The executive order on “religious liberty” that Trump signed Thursday. A draft of the order obtained by the Nation earlier this week would have allowed organizations to discriminate against LGBTQ people in hiring and other decisions. But the final version turned out to be much less controversial; it makes no mention of sexual orientation or gender identity, and instead aims to make it easier for religious institutions to engage in political activity without jeopardizing their tax-free status.
None of this means that moderate Republicans are winning overall. Trump has moved toward the center in a few key areas since taking office, notably on economic policy. But in other areas, such as immigration and criminal justice, Trump has moved aggressively to enact his most controversial campaign promises. And even this week’s victories for moderates could prove short lived; there’s nothing to stop Trump from issuing his LGBTQ order next week. But this week suggests that the Freedom Caucus isn’t the only group of Republicans that can influence policy. That lesson could become even clearer as the health care debate moves to the Senate.
Health care: The uninsured
Almost as soon as the House passed a bill to repeal and replace the Affordable Care Act on Thursday, news spread that the Senate won’t vote on the House bill. Instead, a working group is already drafting a new one. That’s not surprising, given that millions of people would lose coverage under the House bill (24 million, under the original version of the bill, according to the Congressional Budget Office; the CBO hasn’t yet published an analysis of the bill passed by the House, but many experts say the number of uninsured could be even larger in the new version). The bill would also impose massive cuts to Medicaid, the insurance program for low-income individuals, and would reduce subsidies for many of the people who buy their own insurance, both changes that would affect millions of people in states with Republican senators. Several GOP senators have raised concerns about the Medicaid cuts, in particular.
To understand how the House bill would change health insurance options — and why the bill is likely to change so much in the Senate — it helps to look back at who was uninsured before the ACA and who is uninsured now. Before Obamacare went into effect, more than half of the uninsured had incomes below 138 percent of the federal poverty limit, according to 2013 survey by the Kaiser Family Foundation. That income level matters because it’s the current cutoff for Medicaid eligibility in states that expanded the program under Obamacare — these are people who are likely too poor to buy insurance on their own. People who were uninsured also tended to stay that way for a long time: About 80 percent hadn’t had insurance for more than a year and nearly 50 percent hadn’t had insurance for more than five years. They were also relatively young; two-thirds were between the ages of 19 and 44. It would be a mistake, however, to assume the uninsured were just healthy people who didn’t need much care: 30 percent said they had an ongoing health issue.
Today, the uninsured continue to be younger and poorer, on average, than the population as a whole. The Affordable Care Act, a big, messy bill with a host of interlocking provisions, ended up leaving several gaps in coverage. Some are due to politics, or poorly written legislation: For example, there are 2.6 million uninsured people with incomes below the federal poverty limit who live in states that didn’t expand Medicaid but are too poor to be eligible for subsidies to buy insurance. (The ACA was meant to ensure that everyone living in poverty would be eligible for Medicaid, so it only provides subsidies for people with incomes above the poverty line. But then a Supreme Court decision decided it was up to states if they wanted to expand Medicaid, leaving millions in limbo.)
Millions more remain uninsured because they are still too poor to afford the ever-growing cost of premiums. There are also those who choose not to buy insurance, even though the federal government says they could afford to. But not that many of them: Less than 20 percent of the 29 million uninsured people in 2015 paid a tax penalty for not having coverage. (Of course, just because the government thinks these people could pay for coverage doesn’t mean they would consider their options affordable.)
So what does this tell us about what the House bill would mean for insurance? Many of the people who gained coverage under the ACA would risk losing it under the new bill as Medicaid is cut back and subsidies are reduced. Meanwhile, the bill would likely do little to help those who remain uninsured under Obamacare. Its backers argue that by cutting taxes, dropping regulations on the insurance industry and reducing government spending on health care, the bill would increase choice and competition, which would in turn lower premiums. But even if that’s true, the changes won’t do much for the people who have always been most likely to be uninsured, the poor. In other words, it’s likely that millions would be left uninsured under the GOP plan, not because they don’t want coverage but because they wouldn’t be able to afford it. It’s not hard to see why senators might be concerned.
Data integrity: Census in trouble?
This week’s budget deal includes nearly $1.5 billion for the Census Bureau, $100 million more than in 2016. That may sound like a victory for fans of government data. In fact, it’s anything but.
The budget for the census is highly cyclical. Every 10 years, spending soars as the bureau hires hundreds of thousands of census takers to complete the constitutionally mandated population count. Spending drops in subsequent years before ramping up again ahead of the next census.
At least, that’s how it is supposed to work. The Census Bureau is now in the ramp-up period for the 2020 count; next year, it will run a crucial field test that is the last chance to work out any kinks in new data-collection methods. (The 2020 census will be the first conducted primarily online.) The Obama administration requested a budget increase of more than $250 million for the Census Bureau in 2017, with much of the extra money dedicated to getting ready for next year’s test. The final budget increase will be less than half that big.
Still, the bigger threat to the quality of census data could come next year. Trump’s preliminary 2018 budget would give $1.5 billion to the Census Bureau, effectively keeping spending flat in a year when, based on past 10-year cycles, it should be increasing by 60 percent or more. (Ahead of the 2000 census, funding lagged through the first seven years of the cycle, then jumped in 1998.) If Congress doesn’t decide to appropriate more money, the bureau could face a stark choice, said Phil Sparks, a former census official and co-director of the Census Project, an advocacy group. It could cut back the scope of the field test, increasing the risk of a failure in 2020 (imagine the census website crashing as tens of millions of Americans try to log on to fill out their forms). It could make cuts to other programs, such as the annual American Community Survey, a key source of demographic and economic data. Or it could give up on shifting to an online census — a short-term savings that could end up costing $5 billion more over the full 10-year cycle, according to Commerce Department estimates.
“2018, to me, marks the Rubicon for this census,” Sparks said. “We’re now at the midnight hour.”
The environment: Back to fossil fuels
The Trump administration lobbed an administrative grenade at the renewable-energy industry this week, appointing a critic of wind and solar power to head the Department of Energy office that oversees renewable-energy policy.
Daniel Simmons, who was already working at DOE as part of the Trump transition team, has worked at several conservative energy and environmental think tanks and at the American Legislative Exchange Council, a conservative policy group that writes model legislation and has a great deal of power in state politics. He has testified in Congress against the use of DOE loan guarantees for renewable-energy companies and has argued that wind and solar power are inevitably more expensive than fossil fuels and will increase energy costs for families.
It’s difficult to suss out the truth in claims Simmons has made about renewables in the past, largely because the economics are really variable and what you think about them probably depends on your political philosophy. For instance, the DOE’s Loan Programs Office, whose work investing in renewable development Simmons has criticized, has lost 2 percent of its investments — they won’t ever be paid back, usually because the company that took the loan failed. That number has been both touted as a success by people who support the Loan Programs Office’s mission of incentivizing technological innovation (the DOE’s loans outperform private bank portfolios) and criticized as a failure by people who don’t think the government should be in the tech-incentivizing loan business at all.
The question of whether renewable energy is more expensive than fossil fuels is equally complex. As we wrote back in November, the costs vary greatly depending on time of year, regional variables in climate and geography, how you account for indirect costs (such as the impact of coal-associated lung disease or electric grid infrastructure updates that benefit solar power), and what environmental restrictions federal and state governments have placed on fossil fuels. All of that said, though, analyses have shown that wind power — even without subsidies — can be cheaper than natural gas, which is, itself, already cheaper than coal.