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Who Killed The Health Care Bill?

In this week’s politics chat, we talk about — what else? — the apparent failure of Republican efforts to repeal and replace the Affordable Care Act. Those efforts collapsed Monday night when Sens. Jerry Moran of Kansas and Mike Lee of Utah said they would vote against a procedural motion to move ahead with the bill. So is the bill really dead? And, if so, who’s to blame for the bill’s failure? The transcript below has been lightly edited.

natesilver (Nate Silver, editor in chief): Good morning, chatters. Sometimes we have trouble picking a chat topic. And sometimes, when we’re trying to decide on a topic … the GOP’s effort to pass a health care bill collapses! So let’s talk about that.

harry (Harry Enten, senior political writer): Thanks to Jerry Moran and Mike Lee for allowing us to find a chat topic.

clare.malone (Clare Malone, senior political writer): Do we want to talk about the politics of this? The policy of this?

natesilver: Well, Clare, there are basically four questions I want to cover:

  1. Was this predictable? Why were Moran and Lee the ones to kill it?
  2. To whom should we assign blame? What could McConnell have done differently? How much did President Trump matter?
  3. Does McConnell’s new strategy — passing a repeal-and-delay bill — have any chance? And if not, what’s his goal with it?
  4. Is this good news or bad news for Republicans running for Congress next year?

Let’s start with No. 1. How surprised were you guys when you heard this news? Harry, did you snort out your diet orange soda?

perry (Perry Bacon Jr., senior writer): I think the legislation falling apart was predictable. I don’t think I could have picked Moran out of a lineup before a few weeks ago.

natesilver: Perry, your sources have been skeptical of the bill’s chances of passage for a while now, no? Somewhat more than the conventional wisdom held?

perry: Yes, true. This bill was just not popular with rank-and-file senators. Very few were strongly for it.

anna (Anna Maria Barry-Jester, lead health writer): I would say I’m not very surprised. I was also surprised it was Moran, but Kansas has been interesting this year. The state legislature nearly expanded Medicaid with a veto-proof majority.

harry: To answer the question: I wasn’t surprised. There were already two senators who opposed the bill. Only three were needed for the bill to fail. As Anna touched on, Kansas is going through an anti-very-conservative period. And while Moran would have been surprising as a “no” vote a few months ago, he’d previously come out against a version of this bill. There have been more surprising political events over the last year than this bill going down.

perry: So I thought the “no” group would be Rand Paul and Susan Collins (who had already announced that they opposed the motion to proceed) and then Shelley Moore Capito and Lisa Murkowski. I thought Lee would back the bill as long as Ted Cruz did, as they have been allied on issues involving Obamacare. I thought Moran would fall in line, as he is not known as a rabble-rouser. And I thought they would wait for Sen. John McCain of Arizona to get back from his surgery.

harry: Yeah, I think the surprising thing here is that they didn’t even wait for McCain.

clare.malone: I’ve seen the theory floated that this was a coordinated effort to provide cover for other senators who wanted to vote against the bill.

natesilver: Clare, I’m a proponent of that theory! I think people are overthinking why it was Moran and Lee. If Moran opposed the bill, that probably means a lot of senators did. He was just one of the electorally safer ones to do it. (Moran isn’t up for re-election until 2022, for instance, and even then he isn’t likely to face either a serious primary challenge or major problems in the general election.)

clare.malone: It’s sort of being pitched as an anti-McConnell plot.

natesilver: McConnell apparently didn’t know ahead of time, according to CNN’s tick-tock.

clare.malone: Yeah, with people like Sen. Ron Johnson of Wisconsin saying Friday that McConnell was being underhanded.

natesilver: The Johnson thing was a bad sign, I thought. He was basically calling McConnell untrustworthy.

Anna: I believe “a significant breach of trust” were Johnson’s exact words.

perry: The reporting on senators being mad at McConnell is interesting — the idea that they don’t trust him.

clare.malone: Guys, Washington is so Shakespearean right now! So much talk of betrayal from within!

harry: Adam Jentleson, a former aide to former Senate Majority Leader Harry Reid, had a great tweetstorm on Monday night arguing that what Johnson was doing was highly unusual.

perry: Yeah, I read that. But it’s a former Reid aide, so I was skeptical.

natesilver: Meanwhile, according to CNN, Trump was dining on “lemon ricotta agnolotti with heirloom tomato ragout” (aka pasta with tomato sauce) with a group of Republicans when the bill failed.

But let me take one more run at what happened on Monday night. What does it mean that Moran and Lee did this without letting McConnell — or Trump — know ahead of time? Why didn’t they give McConnell a way to save face?

clare.malone: Seems like they wanted egg on his face.

perry: That does go to something unusual happening here that would seem to call for more reporting.

natesilver: Do we know how many firm “yes” votes there were?

harry: 14, according to The New York Times.

clare.malone: That’s not that many, given that this is a marquee piece of legislation.

natesilver: No, it’s kind of pathetic.

So let’s move on to Phase II of our chat … the blame game! I’m giving each of you 100 Blame Points. Your job is to allocate them between the following people: McConnell, Senate moderates, Senate conservatives, Lee/Moran, Trump, Democrats and House Speaker Paul Ryan.

How many Blame Points, out of 100, do you give McConnell?

clare.malone: I didn’t know there was going to be so much math on this quiz.

Uh, 60 points to McConnell? Maybe more?

natesilver: So we have 60 points for McConnell? Anyone want to go higher?

perry: So I don’t know who (Ryan, McConnell, Vice President Mike Pence, probably not Trump) decided that this bill needed to cut Medicaid — not just the Obamacare expansion but to cap Medicaid spending overall. But whoever made that decision made this bill really, really hard to pass. The Medicaid cuts were in both the House and Senate versions of the bill, by the way.

clare.malone: Yeah, I think Paul Ryan gets the next most points. The House bill set a scene.

perry: I might just give Ryan 50 and McConnell 50. They didn’t plan this process well. They had a long time to have legislation ready, and they just didn’t.

natesilver: I’m giving McConnell 70 blame points, Trump 15, Ryan 10 and Cruz 5. (Cruz for being the ringleader of the group that wanted to push the bill to the right, but which may have cost it more moderate support than it gained in support from conservatives.)

anna: Getting through the Senate was always going to be the tough part for this bill. So fault Ryan for poor stage-setting or McConnell, who is supposed to know how to wrangle his people?

natesilver: The fact that random senators like Jerry Moran killed the bill suggest that McConnell wasn’t even close and was doing a really bad job.

clare.malone: What about Trump? Trump has been SO absent from this process — does that make him take more points or kind of excuse him from blame?

perry: This is a case where I give Trump almost no blame. He was basically not involved in the legislative process, leaving the details to Ryan/McConnell.

natesilver: I’m blaming Trump for not being more involved, especially at the early stages of the process when McConnell and Ryan drafted an approach that was going to be so unpopular and politically fraught.

anna: Trump has really not helped the situation. He’s been antagonistic with insurers, and his people ran attack ads against Nevada Sen. Dean Heller, who was one of the key swing votes on the bill!

harry: I was going to go with 50 points for McConnell. Ryan didn’t help because the bill he produced was too far to the right and also made Senate conservatives think they could get away with pushing the bill even further right. I’d go with 20 points for Ryan. Trump is the freaking president. I don’t care if he doesn’t know stuff. It’s not on-the-job training time. There is no curve. I’ll give Trump 20 points too.

clare.malone: The Heller stuff is … interesting strategy.

perry: Ryan wrote the initial Medicaid cuts, so I’m giving him a lot of the blame.

natesilver: Why McConnell and Ryan’s obsession — if you want to call it that — with cutting Medicaid? I wrote last month that McConnell was likely facing a very difficult path, so long as Medicaid cuts and a bunch of tax cuts (some of which were withdrawn in the final version) were the essence of the bill.

anna: That has been a longstanding Republican goal, Nate. I think they thought this was their chance.

clare.malone: I don’t think we’re giving Lee/Moran enough due here if these points are about how the bill was killed.

perry: I do wonder if Lee was going to keep opposing the bill no matter what. I feel like Lee and Paul wanted a bill that was going so conservative that it would have had a hard time getting 50 votes.

natesilver: I guess what surprises me — and it also surprised me about Paul Ryan in the House — is: Couldn’t they just have told conservatives who thought the bill wasn’t conservative enough to go eff themselves?

harry: Apparently, they didn’t think they could do that. Then again, the Freedom Caucus got rid of former House Speaker John Boehner. They may think they can get their way on pretty much everything.

perry: I actually thought telling moderates to eff themselves was the better strategy. The Senate proved me wrong.

natesilver: Everyone thought McConnell was smart to be following Ryan’s playbook. But Ryan had a much bigger margin to work with in the House than McConnell had in the Senate.

clare.malone: I think it’s difficult to tell moderates to screw off on a thing that takes away a benefit to their constituents that’s been enshrined for decades.

anna: I agree, Clare — and the funding reductions over time for Medicaid are enormous. Medicaid is the second-largest expense for most, if not all, states (behind education).

natesilver: My hot take (which comes with a dash of hindsight bias) is that the fact it was so hard to get a bill passed in the House was a bad sign for the Senate bill, and maybe McConnell shouldn’t have been inclined to emulate Ryan’s process.

clare.malone: Rightward tilt of power in the party, Nate. It’s the ideologues who are more likely to hold the normal process hostage.

harry: Funnily enough, many of the pieces written about why the House made a mistake shifting the bill too far to the right are holding up for now. I wasn’t sure that was going to happen.

perry: I found the House passage of its health care bill on May 4 so stunning that I thought it showed legislative acumen and party unity that would carry over. I was wrong.

harry: You weren’t the only one who thought that, Perry.

natesilver: Let’s move on to Phase III of our chat: What’s next?

McConnell announced that he will have the Senate vote on a “repeal and delay” bill that would eliminate Obamacare without immediately replacing it with anything, but then delay implementation of the repeal for two years while they figure out what will take its place.

clare.malone: Well, I just got a news alert saying three senators — Collins, Capito and Murkowski — have come out against the repeal-and-delay strategy. So it looks like that plan is dead already. Which maybe isn’t too surprising given that a lot of people were saying that it was irresponsible to repeal without a replacement option.

anna: Yeah, not too surprising.

First, only a quarter of people think Congress should repeal what it can now and try to write a replacement bill later.

Second, it’s worth noting that a “clean repeal” is still only a partial repeal of the full ACA. It keeps the requirement that insurers cover people with pre-existing conditions, but it gets rid of the individual mandate, the subsidies to buy insurance, the requirement that employers offer coverage and the Medicaid expansion. The CBO estimated that it would leave up to 32 million more people uninsured by 2026 and that premiums would go up by 100 percent.

natesilver: And that includes something like 18 or 19 million more uninsured in the first year alone, if I’m reading that right.

So did McConnell ever actually want a repeal-and-delay bill to pass, or was he just trying to save face?

clare.malone: Feels like salty saving face? But maybe I’m being naive.

perry: I think the repeal-and-delay vote, if it had come to a vote, was always mostly about forcing the moderates to come out against it. That way, McConnell can push blame onto them.

natesilver: How wobbly is McConnell here? If the next six months go badly for him — let’s say they botch tax reform too — could his leadership be under threat?

perry: The No 2. is John Cornyn of Texas. That is an answer. Cornyn has been constantly, constantly wrong in predicting passage of the bill.

natesilver: So Cornyn isn’t a very threatening understudy, you’re saying.

perry: Right. Whatever you think of Ryan, people thought for a while that he would be a future speaker.

clare.malone: But would it necessarily go in that order of succession? Couldn’t you put up a different candidate from the ranks of senators, someone seen as savvier?

perry: I’m not sure who that person is right now in the GOP Senate. Also, McConnell can just privately blame Trump for all that is wrong. Republican senators are leery of Trump. This could work.

clare.malone: Isn’t that a risk, though? To throw the president under the bus? He’s unpopular, but not with a core group of Republicans.

natesilver: Trump has had mixed messaging since Monday night, at least based on his Twitter feed. He’s advocated for repeal-and-delay, but he’s also tried to pre-emptively blame Democrats for the bill failing. So what does Trump want out of this?

harry: Trump wants wins.

perry: A signing ceremony.

anna: Exactly. He has made clear he doesn’t care where the policy ends up. He campaigned on no cuts to Medicaid; this bill drastically cuts Medicaid. And he celebrated passage of the House bill in the Rose Garden and then called that very bill “mean.”

natesilver: See, all that makes me want to assign more blame to Trump. I’m taking away 5 of McConnell’s blame points and giving them to the White House.

clare.malone: They might WANT to blame Trump, but will they? Nothing in the Republican senators’ past behavior leads me to believe they’ll take that stance.

natesilver: I’d think the way the White House went after Heller — and how they’re trying to squeeze Arizona Sen. Jeff Flake — could be very bad for Trump’s relationships with Congress.

But it’s time to move on to PHASE 4: Politics!

anna: Bye! 👋 (just kidding)

natesilver: As a result of Monday night’s developments, are Republicans now more likely or less likely to hold the Senate? (Note that I said Senate and not House; we’ll talk about the House later.)

harry: Minimal effect. The odds continue to be so low for a Democratic takeover that any movement is minimal in my opinion.

perry: This gets to the question of whether it’s better to be a do-little Congress or a pass-unpopular-stuff Congress. I don’t think I really know the answer to that question.

Do we think Heller is better off with this outcome? I think yes, right?

natesilver: Hell(er) yes he’s better off, although still in a very risky position.

clare.malone: I think the people whose seats were in danger are more OK after this bill dies, right?

natesilver: That’s my thinking, Clare. The bill was SOOOOOOOOOOOO unpopular that I think that unpopularity outweighs all other considerations. Cruz could be a weird exception, though. I don’t think he came out of this looking good. And I think he has both more primary problems and more general election problems than people acknowledge.

Let’s close by talking about the House. That’s a more complicated case. If you’re a member of the House in a purple district who voted for the House version of the bill, how are you feeling right now? Better or worse?

clare.malone: Worse. Because you voted for a (basically the same) bill that eventually came to be considered by Senate Republicans as far too extreme, and that can be turned pretty easily.

perry: Not sure. On the one hand, the bill didn’t pass, so you don’t have to defend it. On the other hand, the bill was so unpopular that it was pulled from the Senate floor. Why did you vote for it? The ads are going to air about how you wanted to cut Medicaid from x number of people in your state/district.

clare.malone: You’re going to end up defending it regardless. It’s going to get brought up. Again and again and again.

natesilver: That’s the question, I guess. You’re a purple-district Republican who voted for a really unpopular bill. But is health care less salient given that the GOP didn’t pass anything? (Assuming they don’t regroup.) Or is it still going to be a big issue next year?

clare.malone: Still a big issue. If the Democrats are any kind of smart (jury’s still out on that) they hang the Republicans on their “mean bill,” not on Trump being an idiot.

natesilver: You don’t think it will get drowned out in Russia and “CNN is fake news” and all the other crazy things that will happen over the next 16 months?

clare.malone: The craziness of the news cycle is certainly a thing that’s hard to account for.

natesilver: I’m still going with Occam’s razor here: The bill is SO UNBELIEVABLY UNPOPULAR that anything that puts it further from voters’ minds is a net gain if you voted for it.

I’d also say that a lot of rank-and-file members should be furious with Paul Ryan for putting them in this no-win position, though!

OK, we’re out of time, but any quick closing thoughts?

harry: Tax reform is going to be fun. That’s my thought.

perry: This is a big news event. If Obamacare repeal is dead, this is a huge setback for Republicans and Trump, who could have spent time on other issues instead of trying to pass an unpopular bill. And it’s a huge political win for Democrats.

anna: I’ll also add my usual reminder that there’s a whole lot the Trump administration can still do that will have a massive impact on the health insurance market. Will they enforce the individual mandate, for example? With or without a bill, the issues at hand aren’t going away.

Nate Silver is the founder and editor in chief of FiveThirtyEight.

Clare Malone is a senior political writer for FiveThirtyEight.

Perry Bacon Jr. is a senior writer for FiveThirtyEight.

Harry Enten is a senior political writer and analyst for FiveThirtyEight.

Anna Maria Barry-Jester reports on public health, food and culture for FiveThirtyEight.

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