‘Take it or leave it’

Some conservatives say it represents “Obamacare lite,” not the full repeal they have campaigned on for years. Other Republicans are mindful of policy decisions impacting Americans who have received insurance coverage on the Exchanges or the states that have expanded their Medicaid populations. House leaders have concluded it’s impossible to reconcile these competing positions, so they are plowing ahead with legislation that would fundamentally change the ACA. In doing so, they will effectively dare their members – particularly the most conservative lawmakers – to vote against it. One leadership staffer last week called the GOP leaders’ message to the rank and file as “Take it or leave it.”

At the end of the day, leadership is banking that conservatives will not pass on the opportunity to “repeal” the ACA. The key to this strategy is President Donald Trump, who ran up huge winning margins in scores of House Republicans’ congressional districts. Trump effectively blessed the House legislation this week to give these Republicans the incentive – and political cover – they need to vote for the AHCA. A House floor vote is planned for early April. Assuming it passes the House, the Senate would vote on the reconciliation bill – needing only 51 votes to pass it – before Congress adjourns for a two-week recess. Leaders are not envisioning going to a conference committee to resolve differences in each chamber’s reconciliation bills; the Senate would take up and try to pass whatever the House approves. But the House’s political cross currents also exist in the Senate, where Republicans can only afford to lose two votes, assuming all Democrats oppose the bill.

That’s the plan. It’s a gamble by House and Senate GOP leaders, and it’s possible the plan will go sideways. But leaders believe muscling through a bill – with Trump providing air cover – is the only workable strategy.

For healthcare stakeholders, that process provides limited options to try to shape the final legislation. It’s not clear whether the committees will vote on a “manager’s amendment,” an updated version of the House legislation that could reflect stakeholder input. But the Budget Committee and the Rules Committee will likely make changes to the bill as it moves forward, providing opportunities for stakeholders to weigh in and propose changes – likely not wholesale changes, but potentially narrow changes that could mitigate adverse provisions.