The main thing that the House GOP health care bill accomplished was to give Republicans a way to say they had a plan to repeal and replace Obamacare. The main thing the manager's amendment—a series of changes to the original bill released this week—does is to attempt to placate House Republicans opposed to the original bill, in hopes of creating a bill that can actually pass.
But the original bill doesn't really repeal and replace Obamacare. Similarly, the manager's amendment may not win over enough skeptical Republicans to pass in the House. The American Health Care Act (AHCA) is a bill that so far does not appear to accomplish its most basic political and policy goals.
Currently, there's a vote set for tomorrow, and both the White House and Republican leadership are making an all out push to get the bill over the finish line. But it remains an open question whether or not the bill will win majority support, and one of the reasons why is that its backers aren't really doing much to defend the bill on its merits. In the meantime, the vote looks like a major test of Donald Trump's ability to move legislative—and a potential moment of power for determined House conservatives.
The manager's amendment was loaded with provisions designed to win over the support of skeptical Republicans. The revision added incentives for states to implement Medicaid work requirements (which are structured in a way that provides little benefit to states), allowed states to apply for a flat Medicaid block grant, and pushed forward the elimination of Obamacare's taxes to repeal them retroactively for this year, among other things.
It even included a special provision designed to appeal to New York legislators by blocking the federal government from providing matching funds for dollars collected from New York county governments, which would effectively end a complicated and longstanding Medicaid payment game played by the New York's state government at the expense of county budgets. This was less a systemic reform and more a targeted provision focused on winning the support of a specific group of legislators—the sort of last-minute deal sweetener that gets thrown into a bill that might not survive a vote.
But right now, it looks like it might not be enough.
After the manager's amendment came out on Monday night, Rep. Justin Amash (R-Michigan) said that the Freedom Caucus, a group of conservative House legislators, had enough votes to stop the bill from passing. Rep. Mark Meadows (R-North Carolina), who leads the Freedom Caucus, concurred.
On Tuesday, Trump addressed House Republicans, urging them to support the bill and warning that those who refused risked losing their seats in 2018. Reports indicate he specifically called out Meadows for serving as the point person for Freedom Caucus opposition. ""I'm gonna come after you," Trump said to Meadows in the closed-door meeting, according to The Washington Post.
Yet despite Trump's direct appeal, Republicans still don't appear to have the 216 votes needed to pass the bill in the House. According to Politico, Meadows and others in the know say that there are still enough Freedom Caucus members opposed to the bill to sink it. A count from NBC News this morning confirms that House Republicans do not currently have enough votes to pass the bill.
It's always possible that the bill will pass on a tight vote, with a few no votes flipping to yes at the last minute. But part of what is remarkable about this situation is how uncertain it is with just a day to go. That a bill that supposedly fulfills the GOP's number one domestic policy priority—repealing and replacing Obamacare—for the last seven years might well not pass at all reveals just how little consensus there is around this legislation. (And, of course, even if the bill passes in the House, there is no guarantee it will pass in the Senate, where it can survive just three GOP defections, and where many of the worries about the bill come from the opposite direction of the House Freedom Caucus.)
Even more telling still is that Republican leadership is barely attempting to defend the legislation on its merits. There are basically three arguments for it at this point.
The first is that no Republican should want to block a rare opportunity to pass a bill that would repeal Obamacare. This is more or less the argument being made by House GOP leadership, and by people like Rep. Mo Brooks (R-Alabama), who says that the AHCA vote is a test that will demonstrate who is a true conservative. The problem with this argument is that it assumes that this is an effective repeal bill rather than actually making a case on its policy merits. (Among the reasons to be skeptical of this claim is that, at least according to the Congressional Budget Office, more Americans would be uninsured under this bill than under a straightforward, no-frills repeal.)
The second argument made for the House Republican bill is that Republicans who defect risk losing their seats. This is the argument made by President Trump. It is a purely political argument, one that says nothing about the merits of the policy itself. Indeed, it is unclear if Trump, who has never once described or even attempted to summarize the bill's main policy mechanisms, knows enough about how the bill works to make a policy argument in its favor.
Finally, there is the argument, made by Speaker of the House Paul Ryan, that the bill is a prerequisite for some hypothetical future tax reform legislation. (Last night, Trump made a version of this argument as well.) It is true that passing the health care bill through the reconciliation process now would make certain aspects of the tax reform process—namely permanent large tax cuts—easier later. But that is an argument for tax reform, not for the GOP health care plan.
It is no wonder, then, that the bulk of the Freedom Caucus is, at least for the moment, still holding out. They are being told they must vote for the bill, but they are being given no good policy reason to do so.