When it comes to health care reform, it’s all about the math.
The First Element: Trump and Winning
President Donald Trump hates to lose. He’s about winning until we’re all sick of winning. (His words, not mine). The American Health Care Act, Republican’s attempt to replace the Affordable Care Act, also known as Obamacare, failed. Support was so scarce House Speaker Paul Ryan and the President didn’t even bring it to a floor vote in March.
The press said President Trump lost. Given his vocal support and strong lobbying for the bill, this assessment was accurate, but one the President cannot, and, apparently, will not accept. He sent his team to try to salvage the bill before the April recess. They failed. Which was a bit surprising given that President Trump seems more focused on passing a bill – any bill – than on the substance of legislation.
This is the first number in our health care reform equation: President Trump wants to win and doesn’t care how.
The Second Element: Divided Republicans
It takes a simple majority to pass a bill out of the House. With 434 current members (the elevation of Jim Price to Secretary of Health and Human Services leaves one seat vacant) 218 votes are required to pass legislation. There are currently 246 Republicans in Congress. Having already shut Democrats out of the process, all but 28 members of the GOP caucus are needed to pass a bill; a 29th Republican “No ” vote and the bill fails.
There are about 40 members of the House Freedom Caucus, a group of the chamber’s most conservative lawmakers. The majority of the caucus were united in opposition to the AHCA. In March President Trump blamed them for the bills defeat. In April he sent his emissaries to get their votes.
The Freedom Caucus demanded elimination of some of the ACA’s most popular provisions as the price of their support. These provisions prevent carriers from excluding coverage for pre-existing and requiring health plans include certain essential benefits like maternity coverage. The White House reportedly considered acquiescing to these demands.
The problem, however, was that accepting the Freedom Caucus demands resulted in (relatively) moderate GOP Members abandoning the AHCA. Gaining conservatives votes doesn’t help if the cost is an equal number of moderate votes. There may be a path to pass the AHCA solely relying on solely on Republican votes, but given the divide between conservative and mainstream Republicans, it’s hard to find it.
Which provides the second number for our equation: Republican can’t pass health care reform on their own.
The Third Element: Democrats Want Repair
Democrats, believe the ACA has been good for America, especially for those who, but for the ACA, would have no health care coverage. Most liberal Democrats think the ACA doesn’t go far enough. They won’t be satisfied with anything less than a single-payer system.
Many Democrats, however, think the ACA is generally fine, but in need of critical tweaking to keep it working. Some liberals will hold out for their dream of “Medicare for All,” but even many in their ranks will take a repaired ACA over a broken system or what Republicans are offering.
Which is why Democrats united against the Republican plan. Not that it mattered. Republicans never sought Democratic votes for the ACA.
Democrats want to fix the ACA. That’s the third number and final number in our health care reform equation.
The Math of Health Care Reform Compromise
If President Trump wants to win he needs to move beyond a purely Republican formulation. Otherwise, as shown above, the math doesn’t work. Republicans need the larger numbers Democrats provide to pass health care reform legislation.
How does this math work? Let’s say a health care reform package reaches the floor of the House that attracts 164 Republicans – just two-thirds of their caucus. However, it gains support from 54 Democrats – only one-third of their caucus. The bill moves on to the Senate. In short, it’s easier to find 218 votes among 434 Members than from among 246.
This path makes the challenge before the President straightforward, if difficult: find a legislative package that attracts enough Democratic votes to offset the Republican votes it loses. In the old days (before Washington because hyper-partisan) pragmatists from both parties would meet and hammer out a compromise. That’s what’s needed now. Significantly, there’s plenty of common ground to be found.
There are ACA taxes neither Republicans and Democrats like. Eliminate them. The Shared Responsibility Payments that penalize Americans for going without coverage is universally acknowledged to be ineffective. Fix it. Both Democrats and many Republican want to keep the ACA’s Medicaid expansion. Preserve it.
The path to a compromise won’t be easy, but the equation is simple addition: President Trump wants to win and doesn’t care how PLUS Republicans can’t pass health care reform on their own PLUS Democrats’ want to fix the ACA. The result: compromise.
The biggest obstacle to achieving health care reform is not the math, it’s the politics. Incumbents in both parties dread being “primaried” – Republicans fear being challenged from the right; Democrats from the left.
This is not paranoia. The extremes of both parties will seek vengeance on their less pure teammates. Party leaders and the Administration will need to give these members extensive cover in terms of messaging, campaign money and resources to beat back these attacks. Or they will need to convince the public that failing to achieve health care reform is a worse outcome than the compromise.
This is where President Trump proves he deserves to win. He must demonstrate his self-proclaimed negotiating prowess and his proven marketing acumen can create a political environment where compromise on health care reform doesn’t doom incumbents.
In other words, for President Trump to win he needs to make sure that members of Congress win, too. Otherwise, he loses. That’s politics—and math.
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