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What Paul Ryan And Donald Trump Hope Will Happen On Obamacare This Week

Key GOP senators keep criticizing the American Health Care Act, the bill that top Republicans in the House wrote to repeal and replace Obamacare. So the AHCA, in its current form, has little chance of becoming law.

But a stalling of the AHCA before it even moved to the Senate would be a huge setback for House Speaker Paul Ryan, the White House and a Republican Party that has been promising to get rid of Obamacare for seven years. So Republican leaders, including Ryan and President Trump, will push aggressively this week to get at least 216 of the House’s 237 GOP members to back this bill and push it through the House — even if the AHCA has no future afterward. A vote could come as early as Thursday. How might the week unfold?

What Paul Ryan wants to happen this week

In short: Move the AHCA a bit to the right, then pass it.

Enough GOP members of the House have complained about the existing AHCA that Ryan has agreed to write up a series of modifications. While the formal changes have not been released publicly yet, they are likely to be in two areas: limiting Medicaid eligibility and making insurance more affordable for older people.

The ideas under consideration for Medicaid are provisions to make it easier for states to keep people off of Medicaid coverage if they don’t have jobs; give states block grants for their Medicaid funding, which would give them more freedom to set rules and regulations for low-income health care without much federal oversight; and speed up the rollback of the expansion of Medicaid under the Affordable Care Act.1

The Medicaid limits are designed to placate the more conservative blocs of the party, particularly the House Freedom Caucus, which has been leery of this bill. Conservative lawmakers, including Ryan, have long criticized putting low-income people on Medicaid, which they say creates government dependency.

The work requirements and block grants are likely to get broad support among House Republicans, but accelerating the Medicaid cuts could move more moderate Republicans in the House away from the bill and deepen opposition to it in the Senate, where a number of senators are from states that have greatly expanded their Medicaid programs under Obamacare.

The provisions to help the elderly are aimed at more moderate Republicans who are worried that the bill is too stingy to people who need help to afford health care, particularly after the Congressional Budget Office concluded that the bill would drastically increase costs for low-income people in their 60s. The focus on low-income, elderly individuals also has a political element, as that bloc of voters in many states strongly backed Trump in 2016.

Generally, Republicans are trying to move the bill slightly to the right, hoping to limit “no” votes from the Freedom Caucus, which has about 30 members. But party leaders can’t move the legislation too right, or risk that the 23 members who are in districts that Hillary Clinton won in 2016 and other more moderate members oppose it en masse.

Based on the legislative timetable the speaker has laid out, Ryan will announce these changes to the bill by Wednesday, and they will be included in a so-called “manager’s amendment.”2 Based on this schedule, it seems unlikely the Republicans will have these changes to the legislation reviewed by the Congressional Budget Office, whose report on the initial AHCA bill complicated Ryan’s push to pass it. Democrats are criticizing this move, arguing that before a final vote members and the public should know exactly how the changes made by Republicans will affect costs and the number of people uninsured under the AHCA.

Ryan has said he wants members to vote on the bill Thursday, exactly seven years since the day that Obama signed the ACA into law on March 23, 2010. This vote could slip to Friday, if members need extra convincing. But the Ryan strategy would have the AHCA approved by the end of the week.

The vote is likely to be close. Polls show the AHCA is not very popular with the public, and at least 16 GOP members have already expressed deep reservations about it. But a narrow margin is not unusual for a controversial bill such as this: 34 House Democrats voted against Obamacare in 2010, resulting in its passing 219 to 212.

What could happen instead

Party leaders in Congress, both Democrats and Republicans, typically don’t hold votes they’ll lose. So if Ryan starts saying that the House vote is delayed beyond Thursday or Friday — no matter the rationale he articulates publicly for the slowdown — it’s a good bet there are not 216 votes in the House for the bill. What happens then? Republicans could change the bill further through more amendments. Trump and Ryan could start really holding members’ feet to the fire. You could imagine Trump or Vice President Mike Pence appearing on Capitol Hill this week or having members come to the White House.

Ryan could also go a third route: Hold a floor vote even if he is unsure that the bill has 216 votes. In taking this approach, he would essentially be daring Republicans in very conservative districts to vote against a bill that rolls back Obamacare and is strongly backed by Trump.

If this bill passes the House, Trump and Majority Leader Mitch McConnell will face similar challenges in the Senate: How can you write a health care bill that appeals to moderate Republicans such as Sen. Susan Collins of Maine but also strong conservatives like Texas Sen. Ted Cruz? How do you balance the popularity of the Medicaid expansion with the deep opposition to it among conservative activists and lawmakers? Ultimately, if the AHCA is going to become law, House members may have to do this again. The Senate will make changes, and the House Republicans will have to accept some of those. Obamacare was very hard to pass. It is looking very hard to repeal, as well.


  1. The current version of the AHCA would start limiting the Obamacare Medicaid program at the end of 2019, but some conservative Republicans are pushing for this to happen earlier.

  2. Democrats used similar procedures to make some last-minute changes in the initial passage of what eventually became the ACA.

Perry Bacon Jr. was a senior writer for FiveThirtyEight.