WASHINGTON ― After the House passed its health care bill last week, Senators looked apt to take that dramatically conservative plan, stick it in a filing cabinet, and start over with a more moderate bill ― one that may never be able to pass the House on the way back.
But Democrats may overestimate the level of disagreement between the two chambers. And if the last two months have proved anything, it’s that we’re underestimating the ability of Republicans to accept a flawed bill in the name of winning.
We may also be surprised by what House conservatives could accept from the Senate.
House Freedom Caucus Chairman Mark Meadows (R-N.C.) has already been working with Senate Republicans on what changes House conservatives could live with, knowing that the Senate bill will probably undo some cuts to Medicaid and perhaps a key amendment that brought conservatives onboard in the first place.
“If it’s moving to the left, we just need to make sure we’re not losing too many conservative votes,” Meadows told HuffPost on Friday. “Obviously it’s going to get more relaxed as it relates to the Medicaid expansion.”
One massive change that House conservatives could accept, perhaps even welcome, is to ditch a dominant feature of the House replacement: the advance refundable tax credits.
Instead, conservatives may just take some changes to the Obamacare subsidies.
“The fundamental question is going to come down to the tax credit subsidy in place, or do they drop back to an Obamacare modified subsidy,” Meadows said.
All along, conservatives have insisted that the tax credits might be another entitlement program. But they were willing to accept that feature of the replacement because it could save money and was one of House Speaker Paul Ryan’s favorite health reform ideas. There was also a rider associated with the tax credits that prohibited those funds from going to purchase insurance plans that cover abortion.
That abortion provision looks apt to be removed in the Senate as a consequence of Republicans using a reconciliation bill. (The so-called Byrd rule subjects provisions without a real budgetary impact to a 60-vote threshold.) That could be a real problem for Republicans. A number of conservatives have told HuffPost they don’t see how a bill without a Hyde amendment rider ― which prohibits taxpayer funds from going toward abortions ― could get through the House.
Certainly, if conservatives want to hold the line on that issue, and if moderates remain opposed to what comes back from the Senate, there is a real chance Obamacare could be saved by conservatives who are unwilling to bend on abortion.
“It was made such a predicate,” Meadows said of the abortion rider and Republicans supporting the tax credits. “It’s not just the Freedom Caucus.”
The Senate looks like it will write a bill using the tax credits, potentially offering more assistance for seniors who could see their premiums skyrocket under the House bill, and potentially scaling back some of the tax credits for younger people.
“I’ve had discussions with Sen. [John] Thune [R-S.D.] on an idea to address tax credits for those in their 50s and 60s and the working poor, and he’s had some very thoughtful, meaningful ideas on how to address that that would certainly be accepted by conservatives, if that’s the direction the Senate decides to go,” Meadows said.
If the Senate does move forward in that way, the House will have to swallow a bill that probably does not have those abortion funding prohibitions and could cut the number of insured even more. (The House offered generous tax credits to younger people in an effort to get them into the insurance pool and keep the number of insured high, but it came at the expense of potentially pricing out older Americans who need insurance.)
Again, though, House Republicans just voted for a bill that hardly any of them really liked or even understood. How many members, off the top of their heads, have a real idea how much a 42-year-old making less than $75,000 a year would get in tax credits annually compared to a 28-year-old? How many really care or are basing their support on those breakdowns?
Suffice it to say, on those wonkier but still significant points, the Senate has some leeway to make major changes. But if conservatives are going to draw a line on abortion, that could be a real problem ― the question is whether they would really derail a repeal and replacement of Obamacare over that issue.
The other big item that could be tricky is how conservatives treat their demands on pre-existing conditions. The Freedom Caucus made their support of the health care bill contingent upon the bill allowing states to opt out of provisions mandating that people with pre-existing conditions be charged the same as healthy people. The caucus contends this is the only real way to lower premiums for other people, and that high-risk pools would be adequately funded for sick people.
While Meadows refused to get pinned down on whether he and other Freedom Caucus members could support something from the Senate that didn’t allow insurers to charge sick people different rates, it was clear he was willing to accept some changes to the current provisions. For instance, he discussed a potential amendment that would allow insurers to offer plans that aren’t compliant to Affordable Care Act regulations if they also offered four plans that were compliant.
Senate moderates would likely see through that proposal, the end result of which would be insurers just offering four very expensive plans and trying to get people to buy the cheaper, non-compliant insurance. But there is, at least, some willingness from conservatives to deal.
That flexibility may not extend to completely doing away with the House amendment brokered between Meadows and moderate leader Tom MacArthur (R-N.J.). But it’s also possible the Senate bill will win back some moderate votes, meaning there could be room on the other side to lose more House conservatives.
Of the 20 House Republicans who voted against the AHCA, 17 did so over moderate objections. If the Senate is able to scale back some of the Medicaid cuts, that may provide additional wiggle room in the House, particularly because conservatives themselves weren’t ever really calling for more cuts. Conservatives were more concerned about the 19 states that didn’t expand Medicaid not missing out on federal money.
Meadows said Sen. Steve Daines (R-Mont.) was already working on a proposal that might have a longer wind-down to the expansion but also ensures that non-expansion states are treated “fairly.”
“He’s been very thoughtful for several months about that particular issue, so I think he’ll have a lot to contribute as we move to the Senate,” Meadows said.
The Senate is supposedly writing its own bill, but that individual senators are pre-clearing their changes with Meadows suggests they have an eye toward their legislation eventually becoming law. This is not just a messaging bill. At least not at this point.
Even if the bill came back from the Senate without those key provisions that conservatives wanted on pre-existing conditions, it’s possible to see a pathway toward passage. While dragging the legislation further to the right was the key to getting it through the House, President Donald Trump’s instincts on going after individual conservative lawmakers ― like Meadows, former Freedom Caucus chairman Jim Jordan (R-Ohio), and influential HFC member Raul Labrador (R-Idaho) ― was exactly right.
If you can roll those three ― granted, a big “if” ― almost all of the Freedom Caucus will come along. And it’s still possible to win over some House moderates through a slightly better bill.
House lawmakers are posturing right now over what they could and couldn’t accept. But those lawmakers just demonstrated their willingness to vote for unpopular legislation they don’t really like. It shouldn’t be impossible to see how that happens again.