Photo by Chuck Kennedy; U.S. Government Work

Richard Wagner closely considers the daunting task faced by President Trump of negotiating a health care bill that can pass the Senate with a slim, and fragile Republican majority.

While candidate Trump followed the standard Republican line to “repeal and replace Obamacare”, a reform is more likely.  The House bill officially begins by repealing the entire Affordable Care Act.  However, much of the Affordable Care Act is then added right back in.  I explained which parts will remain and which parts will change in both the drafted House version and the Senate version.

Any health care bill, of course, depends on Trump or Republican legislative leaders and their ability to get the votes in Congress.

The Negotiation

Eight years ago, the Democrats held a “Supermajority” in the Senate.  That is, they had 60 seats out of 100, which is enough to end a filibuster and pass a bill if all 60 stick together.  Despite this, Obama had to make several compromises and break an important campaign promise in order to get anything passed.  That promise?  He promised a “public option”.  That is, the government would have set up a health plan that people could choose to purchase, and it would theoretically be less expensive than private plans, as it would be not for profit.  

In order to get the 60, not 50, but 60 votes he needed; Obama had to agree to a bill that did not have a public option, and that’s how we ended up with Obamacare.  That’s how we ended up with a healthcare law that requires us to purchase for-profit insurance or pay a tax penalty, and there is no public option as an alternative.  

The Republicans have nothing close to a “supermajority”.  They have 52 Senate seats, and it’s a very fragmented Republican Party at that.  Yet, somehow, the filibuster doesn’t even seem to be an issue this time.  This is because the Republicans have made it perfectly clear that they, unlike the Democrats, are willing to use the “nuclear option”, which would effectively overturn the filibuster on the grounds that it is unconstitutional, and allow a bill to come to a vote if only 50 support it.

However, the Republicans only have maybe 37 in favor right now, and, needless to say, 0 Democrats.  Some of that 37 are Senate Republicans who have expressed neither support nor opposition, so even 37 is a fragile number.  

There are basically four ways to approach this.
  1. The Liberty Caucus – Trump could reach out to Rand Paul and Ted Cruz, find a way to give them just enough without losing any of the other 48.  This would likely mean cutting the subsidies mentioned above.  This could pass, maybe, but it would be even more unpopular than the current bill, as many people rely on these subsidies to afford their current plans.  They would have to hope that premiums, including for the not quite elderly (ages 50-65) do not increase any further, and that incomes in the country increase enough to make it more affordable for them.  
  2. The Moderates – Susan Collins and Dean Heller fit this description.  They are worried about the Medicaid cuts in particular.  Though Collins supports funding for Planned Parenthood, she is unlikely to vote no on this bill simply over that.  But she has expressed strong concern for those a little above the poverty level who would lose Medicaid coverage.  If Trump, via Senate Majority Leader Mitch McConnell, could keep enough Republicans on board while maintaining Medicaid funding, or maybe just reducing it by less, than he could reach these moderates, but would definitely lose the Liberty Caucus.  This is unlikely to bring support up to 50 Senators by itself.  
  3. Reach out to Democrats?  – Yes, it is possible.  There might be some moderate Democrats in red or purple states, like Sen. Joe Manchin of West Virginia.  The Republicans have made little effort to speak to them, and they have made little effort to speak to Republicans.  If the Republicans who support the Senate bill were to discuss this with Manchin and other moderate Democrats, they might find some way to get them on board.  It would make the bill more bipartisan, however, and risk angering the Republican base.  
  4. Cave into the Democrats – This, of course, is also possible.  Trump could do what Senate Minority Leader Chuck Schumer wants, and agree to not repeal and replace Obamacare, but simply reform it.  While that is more or less what is already being proposed, Trump would have to agree to even fewer reforms.  If Trump goes this route, the individual mandate likely remains, along with the Medicaid expansion and subsidies, but some modest changes could be made.  Trump might gain some political capital this way, but it may cripple his support among his base.  It could also send a message to Republicans in Congress, however, that either they work with Trump, or they lose.
Likely to stick to the base

Based on Trump’s track record so far, he is likely to focus solely on getting 50 or more Senate Republicans to vote for this.  If, however, he was to reach out to Democrats, while standing firm on the individual mandate repeal, he could shore up some of his support from purple state swing voters who put him in the White House in the “rust belt” states.  Trump will likely need them for his re-election bid in 2020.

Richard Wagner is an Adjunct Professor of Political Science at Florida State College at Jacksonville. He conducts independent study on the American conservative movement and foreign policy. When he is...

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