After a series of deaths and resurrections, the American Health Care Act managed to survive a full vote on the House floor on Thursday. Paul Ryan and the House leadership finally discovered the right mix of policy changes to satisfy recalcitrant hardliners and more moderate Republicans, and the bill squeaked through to passage 217-213. Afterward, elated House GOP members guzzled some celebratory Bud Light and were bused over to a White House press conference with President Trump, where they all laughed and back-slapped each other for this legislative accomplishment.
I hope they had fun at their little party, because now things are going to get raw for the GOP. The American Health Care Act is an atrocious piece of legislation that was passed for all the wrong reasons, and the people who voted for it have invited a political backlash.
The AHCA is not designed to improve the American health-care system. Rather, it represents a massive upward redistribution of wealth — the bill gives the richest people in the country a massive tax cut that is paid for by gouging Medicaid funding. Wealthier and healthier people would get more generous subsidies to purchase insurance under the AHCA while older, sicker, low-income people would be left staring down astronomical annual premium increases.
The legislation was made still worse by the late changes that helped secure its passage. To mollify the hard-right flank of the GOP, the House leadership rewrote the bill to allow states to seek waivers to regulations that prevent insurance companies from charging people with pre-existing conditions more for coverage. Sick people who live in those waiver states will instead be quarantined in high-risk pools, where they'll discover that grossly inadequate federal funding has put affordable coverage out of reach. Women will be forced to contend with an insurance marketplace in which sexual assault, C-section births, and domestic violence are considered pre-existing conditions.
All of this will cause political trouble for Republican House incumbents, especially the attack on pre-existing conditions. The Affordable Care Act's protections for people with pre-existing conditions are massively well-liked — a November Kaiser Family Foundation poll found that 69 percent of respondents viewed them favorably. The AHCA, meanwhile, was absurdly unpopular even before the GOP started undermining those protections, and now the vast majority of House Republicans have cast a vote to allow states to screw over the sick.
Not only did they pass it, they cast those votes without any clear understanding of what, exactly, they were voting for. The revised AHCA was pushed through to passage before the Congressional Budget Office could update its analysis of the bill's projected impacts on insurance coverage and the budget. The old CBO score found that the AHCA would result in 24 million fewer people with health coverage. Assuming the updated CBO analysis returns similar findings, GOP representatives will be hard-pressed to explain the "aye" votes they're already on the hook for.
The potential for AHCA-related political turbulence will also filter down to state-level Republicans. The legislation empowers state governments to seek waivers to pre-existing condition protections. Now that the AHCA has passed the House, Republican governors and state legislators are going to face difficult questions about whether they support this widely disliked bill and plan to obtain waivers that would actively imperil the physical and financial well-being of sick people within their states.
The political lesson everyone should have learned from the passage of the Affordable Care Act is that health care is one of the few issues that actually moves voters. As Nate Silver writes, Democrats who voted for ObamaCare paid a large price in the 2010 midterms — they lost something like 7 percentage points of their vote share. A recent report from the Democratic super PAC Priorities USA found that health-care concerns are "a critical motivator for both Democratic drop-off voters and persuadable Trump voters." Of course, whatever price House Republicans pay for passing the American Health Care Act depends largely on how the Democrats approach the issue.
The party can't just assume that the GOP's cruelty and ineptitude will be enough to bring Democrats back to power. The glaring awfulness of the AHCA is an opening for House Democrats to lay out a more progressive health-care vision and rally voters around it. They could endorse a public option for the ObamaCare exchanges, or make Charles Krauthammer's worst fears come true and push for full single-payer. (I have to note that the latter idea has already been shot down by Nancy Pelosi as being too outside the mainstream.)
For the moment, though, Democrats are content to harangue against the American Health Care Act for being the massively cruel and poorly conceived piece of legislation that it is. They should absolutely spend every day from here until the midterm elections reminding voters that House Republicans voted to eviscerate Medicaid and snatch health coverage from sick people so that Donald Trump could have a tax cut.