Against the Grain

Reading the Health Care Tea Leaves

Why health care reform is likely to pass the House, but face trouble in the Senate.

President Trump and Health and Human Services Secretary Tom Price arrive on Capitol Hill on Tuesday to rally support for the Republican health care overhaul.
AP Photo/J. Scott Applewhite
March 21, 2017, 8 p.m.

Pres­id­ent Trump’s biggest polit­ic­al as­set is his base’s un­yield­ing sup­port, and it’s the clearest reas­on why health care re­form is likely to pass through the House on Thursday—if only by the nar­row­est of mar­gins. The pres­id­ent be­latedly de­cided to spend his polit­ic­al cap­it­al this week by meet­ing with House Re­pub­lic­ans to rally them be­hind health care re­form, and threat­en­ing them with primary chal­lenges if they’re dis­loy­al. He echoed House Speak­er Paul Ry­an’s re­mind­er that if health care fails, his en­tire agenda is in jeop­ardy. Those pleas should be enough to keep the GOP’s health care over­haul alive.

Trump and Ry­an are fight­ing a two-front war in their at­tempts to per­suade skep­tic­al mem­bers about the mer­its of the health bill. To pla­cate swing-dis­trict mem­bers, Ry­an has been fe­ver­ishly work­ing to in­crease fin­an­cial as­sist­ance for older voters wor­ried that they would be pay­ing more for health in­sur­ance un­der the Re­pub­lic­an re­forms. To pre­vent hard-line con­ser­vat­ives from de­fect­ing, Trump has been dis­patched to lever­age his own pop­ular­ity in their dis­tricts against them.

Both sides have much at stake: Trump will be test­ing the de­gree of good­will he has with mem­bers rep­res­ent­ing dis­tricts where he won over­whelm­ingly. Throughout the cam­paign, Re­pub­lic­ans with polit­ic­al fu­tures to pro­tect fell in line be­hind Trump—des­pite all his bag­gage—be­cause of the de­gree of loy­alty rank-and-file Re­pub­lic­ans had to­wards their nom­in­ee. That de­gree of par­tis­an loy­alty hasn’t changed since the elec­tion, and it’s the most ef­fect­ive tool for Ry­an to util­ize as he lob­bies his waver­ing mem­bers. But if enough hard-line con­ser­vat­ives stick to their prin­ciples to scuttle the bill, or privately fear a back­lash from con­stitu­ents over the health care changes, the per­cep­tion of Trump be­ing a world-beat­er will take a beat­ing.

Con­gres­sion­al Re­pub­lic­ans at­trib­ute grow­ing mo­mentum be­hind pas­sage in the House to Trump’s last-minute en­gage­ment. For a while, he kept some dis­tance from the sig­na­ture le­gis­la­tion. In pub­lic state­ments, he sounds all too eager to del­eg­ate the dirty work to Ry­an and Sen­ate Ma­jor­ity Lead­er Mitch Mc­Con­nell. Des­pite his bully pul­pit, he has only spar­ingly used his Twit­ter feed and its 26 mil­lion fol­low­ers to sell his sup­port­ers on the le­gis­la­tion. At cam­paign-style ral­lies, he fre­quently bur­ies his health care sales­man­ship at the end of his speech.

At a rally in Ken­tucky on Monday, Trump hardly soun­ded en­thu­si­ast­ic about the mer­its of the health meas­ure. He in­stead framed it as a ne­ces­sary pre­requis­ite so Re­pub­lic­ans could then fo­cus on cut­ting taxes and ne­go­ti­at­ing tough­er trade deals. He didn’t try to sell any of the spe­cif­ic as­pects of the le­gis­la­tion, only not­ing that it would re­peal Obama­care. As Politico’s Shane Gold­mach­er put it: “Trump is in­creas­ingly talk­ing about health care like the ve­get­ables of his agenda—the thing he must be­grudgingly fin­ish in or­der to get what he really wants.”

Trump con­siders him­self a mas­ter in the art of the deal, but in real­ity he’s as mas­ter­ful in the art of de­flec­tion. So his mere own­er­ship of the bill—and the threat of polit­ic­al con­sequences—at Tues­day’s Re­pub­lic­an Con­fer­ence meet­ing was an im­port­ant sign that he’s fully on board with Ry­an’s agenda. (For his part, Ry­an has praised Trump’s ef­forts ef­fus­ively, a sign of Trump’s im­port­ance in the equa­tion.)

Ry­an, mean­while, needs to con­vince most of the 24 House Re­pub­lic­ans who rep­res­ent dis­tricts that voted for Hil­lary Clin­ton in 2016—along with an­oth­er dozen or so mem­bers rep­res­ent­ing com­pet­it­ive dis­tricts. Ry­an has strong re­la­tion­ships with these mem­bers, and has been par­tic­u­larly ef­fect­ive in selling the mer­its of the le­gis­la­tion to these vul­ner­able rep­res­ent­at­ives. My col­league Daniel Ne­whaus­er re­por­ted that sev­er­al of these en­dangered mem­bers were among late-break­ing sup­port­ers Trump re­cog­nized Tues­day, in­clud­ing Reps. Martha Mc­Sally, Tom Ma­cAr­thur, and Car­los Cur­belo. If Ry­an can hold most of those in the middle, he can af­ford to lose some de­fect­ors from the party’s right flank.

The math in the Sen­ate is much more dif­fi­cult. Already two Re­pub­lic­an sen­at­ors—Ken­tucky’s Rand Paul and Arkan­sas’s Tom Cot­ton—sound un­yield­ing in op­pos­i­tion to the latest House le­gis­la­tion. The two Re­pub­lic­an sen­at­ors fa­cing com­pet­it­ive reelec­tions in 2018—Nevada’s Dean Heller and Ari­zona’s Jeff Flake—will be chal­len­ging to win over. Un­pre­dict­able mod­er­ates such as Maine’s Susan Collins and Alaska’s Lisa Murkowski will be tough sells, as well. As im­press­ive a strategist as Mc­Con­nell is, there may be no way to thread to­geth­er the com­pet­ing, dis­par­ate in­terests.

The polit­ic­al geo­graphy is dif­fer­ent in the House, where Ry­an’s good­will with mod­er­ates and Trump’s deep pop­ular­ity in ruby-red dis­tricts should get Re­pub­lic­ans to the 216 votes they need. If the le­gis­la­tion doesn’t pass that bare threshold, it raises ser­i­ous ques­tions about their polit­ic­al clout—and the fu­ture of more am­bi­tious ef­forts go­ing for­ward.

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