Down to the Wire, Healthcare Reform Becomes a Matter of Trust

With a vote on the American Healthcare Act - written by Speaker Paul Ryan and his colleagues in the house and supported by President Trump - expected on the house floor by Thursday evening, all sides in the debate are scrambling.  

With cost-cutting at the top of the list of demands by conservatives, there were signs of movement by Ryan and Trump late on Wednesday, including, but not necessarily limited to, the possible reduction of “essential benefits” included in the bill.  This would reduce the number of covered benefits required by the government and thus lower projected premiums.

But for this bill - and the entire process of healthcare reform - to succeed, it will require something in short supply these days, particularly in Washington: trust.  Innumerable polls reveal that an overwhelming majority of Americans no longer trust their government.  But right now, the matter of trust not in politicians, but between politicians has become the central issue as the house bill on healthcare reform comes down to the wire.

Trust between GOP politicians in the house and senate will be required for this legislation to avoid a crashing defeat that could possibly signal a reversal of fortune for Republicans who won control of both houses of congress and the White House.  But such trust has been in short order in most quarters since the legislation was first rolled out.

Conservatives in the house generally trust Speaker Ryan, but not so much on this bill.  They find it an unacceptable adaption of Obamacare.  Ryan in turn does not appear to trust conservatives to ultimately support the bill, even after he has acceded to some of their demands.

Conservatives in the house also do not trust the senate, where they fear an already insufficiently conservative bill will be watered down even further.  And the most conservative senators do not trust their moderate colleagues - fearing the same moderating influence on the bill as their conservative colleagues in the house.

Conservatives also do not trust the promise that, once this bill becomes law, HHS Secretary Tom Price will be able to effect an acceptable level of regulatory changes in what’s been termed “Phase Two” of a three-stage process of reform.  And they don’t trust that the “Phase three” additions to reform - particularly the ability buy insurance across state lines and tort reform - can garner the necessary 60 votes in the senate to pass into law.  Thus, they want all the good stuff included in the current bill about to come up for a vote.

Conversely, many legislators involved in this battle accept the assertion that those phase three reforms cannot be included in this first phase because they don’t trust arcane rules about what can or cannot be included in the budget reconciliation process employed by the GOP because it requires just fifty-one votes in the senate rather than the sixty required in the normal legislative process.  They do not trust the functionary known as the senate parliamentarian to do what they believe is the right thing, even though that parliamentarian could possibly be overruled by Vice-President Pence acting as president of the senate.

And conservatives don’t seem to trust that President Trump, facing the political necessity of succeeding in his first major foray into the legislative process, will hold the line against a moderate bill.  Let us not forget that most conservatives in congress did not trust Trump - until he became the president and they quickly understood the need to work with him.  But they still don’t consider him one of them, and seem to believe - perhaps with good reason - that the president will sign whatever is put in front of him.

Conversely, a smaller group of moderate Republicans don’t trust their conservative colleagues to avoid overreach with what they believe is a excessively radical approach to healthcare reform.  Those moderates don’t trust that their constituents will support a bill which reduces the number of insured, whether that is because of the removal of the much-reviled Obamacare mandate or not.

In the end, it seems that the only thing virtually all congressional Republicans trust is that the Democratic left and their cohorts in the establishment media will attack whatever reforms are ultimately passed.  They trust that the axis aligned against them will focus almost exclusively on the number of people who will “lose” their current coverage (many by choice when they are no longer required by law to purchase health insurance) and the premiums which the CBO predicts will rise in the initial stages of implementation, even as the same report predicts a reduction in premiums in the long run.

So when it comes down to actually casting their votes, just how much trust will Republicans be willing to place in one another?  How willing are they to pass a bill that is not ideal for either conservatives or moderates?  That is the $64,000 question.  And the answer will go a long way in determining whether voters who granted the GOP so much power in the last election will view the end result as an affirmation or betrayal of their trust.