Political Outlook For The GOP’s Health Insurance Plan

The House GOP has released its highly anticipated health insurance plan to reform the Affordable Care Act (ObamaCare). The American Health Care Act (you can read the details here) will now be officially marked up by two House committees, Energy and Commerce and Ways and Means.

Assuming the bill that emerges is essentially that of the plan as it currently stands, the proposal faces an uphill climb to become law.

There are several key groups to keep an eye as the bill moves through the legislative process.

House Democrats:

ObamaCare passed on a straight party line vote and if the AHCA is going to pass it’s almost certainly going to be without any Democratic votes. There’s absolutely no incentive for one let alone a handful of Democrats to cross the aisle and vote with the Republicans.

Support for ObamaCare has risen to new heights since the election and a recent Pew poll shows overwhelming support among Democrats.

As in the past, there are deep partisan divisions over the health care law. Democrats overwhelmingly support the law, with 85% expressing approval. Among independents, about half (53%) approve of the health care law, while 45% disapprove. By contrast, Republicans broadly disapprove of the law (89%); just 10% express approval.

Combine that with the general antipathy of Democratic voters to all things Republican and President Trump and there will simply be no appetite among House Democrats to lift a finger to help reform ObamaCare along Republican lines.

Democrats who supported ObamaCare in potentially swing districts have long since been defeated in the 2010 and 2014 GOP waves. The survivors are mostly from safe liberal districts where the plan is popular. Any Democrat who does vote with the GOP on this is essentially putting a target on their back begging for a primary challenge from the energized left-wing of the party. Almost all politicians have a stronger sense of self-preservation than that.

House Republicans:

Without any Democratic votes, the GOP will have to do all the heavy lifting. There are currently four vacancies in the House meaning 216 is a majority. The GOP has 237 seats so they can lose 21 members of their caucus and still pass the bill. 22 and it’s dead.

Where might there be 22 Republicans willing to vote against this bill? The 30 member House Freedom Caucus would seem to fit the bill. Many of these small government conservative/libertarian leaning members have expressed support for Senator Rand Paul’s more market oriented reforms (a plan that would almost certainly cover fewer people) and/or outright hostility to the plan as announced.

It’s also possible that more moderate members might vote against the plan over concerns that not enough people will be covered or that states will be left with major budget shortfalls due to potential changes in ObamaCare related Medicaid expansions. A handful voted against an earlier procedural vote starting the reform process, mostly over concerns no plan had been released. It’s possible these Republicans will be satisfied by the plan but it’s a group worth keeping an eye on.

The calculations of both these groups will be similar in the end. Do they want to be responsible for killing the GOP’s plan to reform ObamaCare after the party ran in 4 straight elections on “Repeal and Replace”?

The more moderate members are less likely to rock the boat on a vote where leadership needs them than the Freedom Caucus members are but the latter have something to consider as well. For years the fear of a primary challenge from the right has worried GOP members. But now the shoe is on the other foot. Trump is very popular in the districts of Caucus members, sometimes running ahead of the members in their own districts. Will they be the ones who fear the threat of a primary challenge from a coalition of more populist Trump supporters and establishment figures? In 2016, then Freedom Caucus member Tim Huelskamp of Kansas lost his primary to a GOP establishment challenger. Surviving members may be on guard over that bit of recent history.

Should the bill survive the House it will go to the Senate where under the “reconciliation” process it will only need 51 votes to pass.

Here the dynamic is similar but different in one important respect than in the House.

GOP Conservatives:

Three Republican members, Ted Cruz (TX), Mike Lee (UT), and Rand Paul (KY) have expressed concern about anything less than full repeal and replacement with a smaller, more market friendly program. Should all three vote against the plan that would leave the bill with 49 Republican votes.

Lee and Paul were reelected last year, so they likely aren’t very worried about primary challenges. Ted Cruz however is up for reelection next year. After spending years building his brand as the leader of the conservative wing of the Republican party in the Senate (to borrow from Howard Dean’s self-description in the 2004 presidential primary), he’s been a loyal team player thus far. He even served as the GOP’s lawyer of sorts in a CNN debate on health care with fellow Senator Bernie Sanders (I-VT). There was some talk he might face a challenge in next year’s GOP primary, with House Homeland Security Chairman Mike McCaul cited as a potential challenger. That seems to have faded as the two recently penned an op-ed together.

Assuming these three vote no, that would leave the GOP at least one vote short of enabling VP Mike Pence to cast the deciding vote.

As in the House there are some Senate Republicans who may have reservations over the plan due to potential changes in the number of people covered and Medicaid costs to their states.

But GOP Sens. Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, Rob Portman of Ohio and Lisa Murkowski of Alaska said they are opposed to House changes to the Medicaid program for poor Americans. The ACA allowed states to expand Medicaid via a generous federal funding formula, and 31 states plus the District of Columbia took advantage.

Senate Democrats:

If three GOP Senators vote no (far from given but assumed to play out the scenarios), unlike in the House there is the potential for getting at least one Democratic Senator on board to produce the 50-50 tie that would enable Pence to vote yes.

The most likely source of support comes from the 10 Democratic Senators up for reelection in 2018 from states Trump won in 2016. Here’s how they’ve voted so far on Trump cabinet picks.

And of that group Senator Joe Manchin of West Virginia stands out. This is one of his campaign commercials from 2012…

Manchin has also boasted of his relationship with the President, including his ability to speak with Trump directly. Even with three possible GOP defections, it’s very likely Senate Majority Leader Mitch McConnel (R-KY) will get to 50 votes.

That just leaves the President and he seems mostly on board.


The issue of negotiations is interesting. With whom does he envision negotiating? House and Senate conservatives? Moderates worried about coverage and protecting their state’s Medicaid funds? Or Senate Democrats from the states he won?

[Update: Secretary of Health and Human Services Tom Price writes to House committee chairman saying the administration is fully on board with the House GOP plan.]

It’s pretty clear that by presenting a plan in final form with quick markups and no hearings, the House leadership sees this as basically a take it or leave it package. If Trump does begin to negotiate, will he help keep one group of Republicans on-side in a way that doesn’t cause the other wing to harden their opposition.

After nearly 8 years of opposition to ObamaCare the GOP has their chance to have a say on it. They have a plan, now they have to sell it to their members and the public.