What Went Down On Health Care This Week

Rep. Mark Meadows of North Carolina, the head of the House Freedom Caucus, is already criticizing “skinny repeal,” according to Capitol Hill reporters. But first things first: Conservatives in the Senate may be okay with the “skinny” approach. Here’s what Rand Paul said, per Politico, “I’ve always said I will vote for any permutation of repeal.” A spokesman for Mike Lee was non-committal. I had not quite realized this initially, but skinny repeal or something like it has the potential to unify moderates and conservatives in the Senate. It is a kind of “pure repeal,” like Paul favors, in that it doesn’t require him to vote for any kind of new health policy that benefits insurers or creates new regulations. But it doesn’t gut Medicaid, which Dean Heller and the moderates oppose. (Heller has already suggested that he supports this idea.) The only problem is that we aren’t sure that skinny repeal, particularly getting rid of the individual mandate, would actually work in terms of policy, or if it would cause even higher premiums. (Health care experts are actually pretty sure it won’t work. Look at the Twitter feed of the Kaiser Family Foundation’s Larry Levitt, who is very skeptical.) I would not be surprised to see Republicans look for a repeal of the medical device tax and the employer mandate but try to find a way to pass something that creates incentives for people to buy insurance before they get sick (which is the point of the individual mandate).

Trump and other Republicans have repeatedly implied that problems in the Obamacare marketplaces, such as those that might occur under a “skinny repeal bill” that repealed the individual mandate, could create political problems for Democrats. The evidence suggests that Republicans would take most of the blame instead. Start with a poll that asked directly about this question. In April, the Kaiser Family Foundation’s monthly survey asked voters whether they thought former President Barack Obama and Democrats or President Trump and Republicans were more responsible for “problems with [Obamacare] moving forward.” Some 61 percent of respondents said Trump and Republicans would be more responsible, as compared to just 31 percent who said they’d assign more responsibility to Obama and Democrats. There’s also the problem that the public trusts Republicans less on health care overall. An average of recent polls from Gallup, NBC News and George Washington University find that Democrats hold a 50-35 lead over Republicans on trust on health care. The Democratic advantage had narrowed in this category in the years immediately following the passage of Obamacare — but it’s since opened back up again as Republicans have spent the past several months trying to pass various unpopular iterations of their health care bill. Finally, there’s the general principle that the party in power is blamed for the country’s problems. Economic conditions have a significant effect on an incumbent president’s chance of being re-elected, for example, even though presidents themselves don’t usually affect the economy all that much. Skinny repeal may nevertheless be less politically costly than some of the alternatives. But Republicans are naive if they expect to escape blame for whatever problems it creates.

No one knows for sure right now what will be in the so-called skinny repeal. But if it largely leaves alone Medicaid, as most indications are so far, this is a huge shift, politically but also in terms of policy. The cuts to Medicaid — both to the Obamacare expansion and, in particular, to the traditional program — in both the House and Senate versions of this legislation have always seemed like an overreach in terms of the politics. By making cuts to traditional Medicaid, this legislation was not just a repeal of Obamacare but an effort to use the Obamacare repeal as a vehicle to accomplish a long-held but not very popular conservative goal: reducing Medicaid spending. Those cuts helped galvanize the left, which could point to the effects that the cuts would have on seniors, the elderly and disabled people. Traditional Medicaid has heavy benefits for these groups, while the Obamacare expansion of Medicaid targets uninsured adults who are generally working-age and not disabled. These Medicaid cuts would also take away money from states, which led to vocal opposition from Nevada’s Brian Sandoval and Ohio’s John Kasich, two Republican governors who have been blasting the Obamacare repeal effort for weeks. If the Medicaid cuts are out, Alaska’s Lisa Murkowski and Nevada’s Dean Heller become much more likely to vote for this bill. But it’s possible that conservative groups such as Heritage Action will oppose that move and make this into a conservatism test, potentially turning Rand Paul, Ted Cruz and Mike Lee against this more limited repeal. And can the conservative House Freedom Caucus support this direction? There’s talk that this provision is just a way to get the bill through the Senate and then Republicans will move back toward a more conservative version of this legislation in conference. I’m not so sure. It would seem to me that the most passable version of Obamacare repeal in both chambers would be whatever Heller can support. If this skinny repeal (or something else that doesn’t include Medicaid cuts) passes, the middle point between the House and Senate bills will be much less conservative than it appeared that it would be a week ago. That affects the conference process. If skinny repeal becomes the legislation the Senate passes, this is a big, important shift.