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The House health care battle: What's at stake?

Donovan Slack, and Gregory Korte
USA TODAY
The Capitol is seen at dawn on Jan. 18, 2017.

WASHINGTON — The House battle on overhauling health care represents the first major legislative test since Americans put Republicans in charge of Washington last November.

President Trump, House Speaker Paul Ryan, R-Wis., and Senate Majority Leader Mitch McConnell, R-Ky., have all thrown their weight behind the American Health Care Act.

The bill, as it stands, would replace swaths of the Affordable Care Act, a signature legacy achievement of President Barack Obama. It would eliminate requirements that individuals maintain health insurance at all times and that larger companies provide it to employees, while keeping provisions allowing children to stay on their parents' plans until age 26 and prohibiting insurance companies from denying coverage based on pre-existing conditions.

But it would also reduce tax credits for individuals buying private insurance, as well as the amount of money provided to states for Medicaid. The nonpartisan Congressional Budget Office predicted last week that it would also increase the number of uninsured Americans by as many as 24 million over the next 10 years.

Republicans have been divided, with conservatives saying they want full Obamacare repeal and many moderates saying this is the best they’re going to get. Democrats are expected to unanimously oppose it. The House vote on the bill, which still would need to pass the Senate, could presage how future legislative battles will play out and has ramifications far beyond health care. Here’s what’s at stake:

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President Trump

President Trump walks to a meeting with House Republicans on Capitol Hill on March 21, 2017.

For Trump, now 61 days into his first 100 as president, the health care vote represents a key early test of his ability to convert his electoral victory into legislation. After all, Republicans have controlled Congress for more than two years. The only missing ingredient was a Republican president’s signing pen.

The 10 bills Trump has signed so far have been either non-controversial measures or up-or-down resolutions to overturn specific Obama-era regulations. The American Health Care Act is far more sweeping: Not only does it largely repeal Obamacare — something Republicans agree on — but it builds a new health insurance system to replace it. Depending on who's talking, that plan has been branded as "Trumpcare" or "Ryancare."

Trump has already put significant political capital behind the effort, with near-daily meetings with lawmakers at the White House— including 18 House Republicans on Wednesday. He’s even suggested that Republicans who don’t get on board may face opposition in GOP primary elections next year.

It would be "historically unusual" for a president to suffer such a huge legislative loss in his first hundred days, said Casey Dominguez, a political science professor at the University of San Diego, who has studied presidential honeymoons. That's especially true for Trump, who has a double advantage of being a new president whose party controls Congress.

But if he does lose, it probably won't have much impact on other issues. Presidents "do learn how to manage relations with Congress as time goes on," Dominguez said, and Trump 's political fortunes have been particularly resilient.

White House press secretary Sean Spicer said Wednesday that failure was not an option. "There is no plan B. This is it. There's a plan A and a plan A," he said. "This is the only train that's leaving the station."

Speaker Paul Ryan

House Speaker Paul Ryan, R-Wis., speaks to the media after a House Republican meeting attended by President Trump on March 21, 2017.

The looming House showdown is an acid test of Ryan’s ability to deliver on the promise of unified Republican rule.

“We as a party have been an opposition party for 10 years … now, in three months' time, we have to go from being an opposition party to being a governing party,” he told talk radio host Jay Weber on Wednesday.

Ryan is calling it his party’s “rendezvous with destiny.”

But it is also the sternest measure by far of his 16-month-old tenure as speaker, of his leadership style, salesmanship, deal-making skills and capacity to corral a GOP caucus united in disdain for Obamacare but fractured over what should take its place.

Winning House passage Thursday would be a provisional victory; the GOP health care plan would still face daunting odds in the Senate. But failure to pass a bill in the House would damage Ryan’s speakership and undermine his far-reaching conservative agenda, which for political, parliamentary and budget reasons hinges on early repeal of the law.

Losing this vote “makes the speaker look weak,” says Matt Green, a Catholic University political scientist and expert on the office of House speaker. “It empowers skeptical groups in his party, particularly the Freedom Caucus, and emboldens them to challenge Ryan on future bills. It could arguably worsen the relationship between president and the speaker.”

Republicans

Rep. Mark Meadows, R-N.C., is pictured in 2013.

The leader of the staunchly conservative House Freedom Caucus isn’t mincing any words about how important the vote is for his group.

“This is a defining moment for our nation, but it’s also a defining moment for the Freedom Caucus,” Rep. Mark Meadows, R-N.C, chairman of the caucus, said. “And so, when we look at that I don’t think there’s a more critical vote for the Freedom Caucus than this.”

The group of roughly three dozen lawmakers who aren’t afraid to buck party leadership generally believe the bill does not go far enough in repealing the Affordable Care Act, and they could have the votes to sink it — if they stick together.

If that happens, the caucus, which already helped usher former speaker John Boehner out the door, could gain even more leverage in future legislation. But blocking it could also leave the group with the not-so-re-election-friendly distinction of aiding continued gridlock in Washington — despite Republicans having control of the White House and both chambers of Congress.

And it would leave Republicans as a whole reeling, fractured and defeated in the first major legislative battle they took on since winning in November.  "If it doesn’t work, it’s not the end of the world, but it’s certainly a major setback,” said Rep. Tom Cole, R-Okla., who as deputy whip for House Republicans is responsible for helping to "whip" votes in line.

Democrats

House Minority Leader Nancy Pelosi and former vice president Joe Biden attend an event on Capitol Hill on March 22, 2017, marking seven years since former president Barack Obama signed the Affordable Care Act into law.

While they don’t have majorities in either chamber on Capitol Hill, Democrats are trying to rally the support of the public to their cause. The party rolled out former vice president Joe Biden on Wednesday hoping to highlight the benefits of the Affordable Care Act and preserve the law.

Appearing at a rally on the U.S. Capitol steps with fellow Democrats and people who have benefited from the 2010 law, Biden said the Republican legislation is a “tax bill” that would transfer close to $1 trillion, now spent on benefits, to people who don’t need the money, and only benefit drugmakers, insurance companies and medical device manufacturers.

It would be a significant blow for Democrats if the House bill passes. If it becomes law, it would essentially wipe a key achievement from the legacies of Obama and also Minority Leader Nancy Pelosi, D-Calif., who as speaker in 2010 helped spearhead the passage of the Affordable Care Act.

If the Republican bill fails, it would strengthen somewhat the Democrats' position. Republicans could be forced to use another legislative route that requires 60 votes in the Senate — a margin they can't reach without Democrats.

Senate Minority Leader Chuck Schumer, N.Y., on Wednesday echoed Biden’s 2010 remark after Obamacare passed, saying it would be a “BFD” if Democrats could beat “Trumpcare” and prevent it from passing.

The health care industry 

Nearly all of the health care industry is nervously bracing for whatever’s in store in the administration’s three-pronged strategy to replace the ACA. But the Republican legislation pending in the House vote carries the biggest risk for hospitals if it becomes law.

Hospitals are required by law to at least stabilize patients who show up in their emergency rooms. That makes the expected increase of millions of uninsured patients a huge threat to their bottom lines because far more patients won’t be able to pay, says Al Kinen, a Rochester, N.Y.-based health care consultant whose clients include hospitals.

“Hospitals are getting barraged as it is — especially those serving people on Medicaid and who are uninsured,” he says.  “These people don’t have enough money to pay for health care and the rest of life.”

The growing field of companies that facilitate virtual doctor visits — known as telemedicine — could help keep uninsured people out of costly emergency rooms and away from unnecessary inpatient care to help manage costs.

“Regardless of what happens in Washington,” Nim Patel, a physician and chief medical information officer at Teladoc, says this less expensive mode of care offers the kind of value needed. Still, she notes that “we prefer for people to have health coverage and early access to primary care and behavioral health care.”

Contributing: Craig Gilbert, Eliza Collins, Maureen Groppe, Jayne O'Donnell, Nicole Gaudiano and Deirdre Shesgreen

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