Senate Majority Leader Mitch McConnell (R-Ky.) has a reputation in Washington as a strategic genius. So when he introduced the new version of the Republican health-care bill on Thursday, some political observers expected to be dazzled by whatever he drew up. Instead they witnessed a very familiar play.
Months ago, House Speaker Paul Ryan (R-Wis.) was finally able to pass TrumpCare through Congress' lower chamber, after his first attempt failed, by inserting new provisions undercutting two key ObamaCare regulations. That brought conservative hardliners on board, while Ryan relied on raw tribal pressure to get the moderates in line.
Now McConnell finds himself in the same predicament in the Senate, caught between Republican hardliners and moderates. And surprise, surprise, he has introduced a deregulatory gambit to keep the hardliners on board while more or less ignoring the pleas of the moderates.
In short, McConnell has lifted a page off Ryan's playbook. But this time, it's probably not going to work.
On the right, it sounds like McConnell's biggest headaches are Sens. Rand Paul (R-Ky.), Mike Lee (R-Utah), and Ted Cruz (R-Texas). So the Senate majority leader's solution is an amendment based on an idea suggested by Cruz. ObamaCare applies a raft of regulations to all health coverage plans on the market: They have to include a whole bunch of essential benefits, they have to treat people with pre-existing conditions the same as healthy people, they have to limit waiting periods, they have to meet certain actuarial requirements, and so on. But in the new amendment, an insurer would be allowed to sell plans that don't comply with those regulations so long as it sells at least one plan on the ObamaCare exchanges that does.
This setup would have all sorts of nasty side effects, though. Sick people would sign up for the more comprehensive plans on the exchanges, while healthy people would flock to the skimpier plans sold off the exchanges. That would drive costs way up for the comprehensive plans, drastically increasing their premiums, while the skimpier plans outside the exchanges would be far cheaper. The market would fracture into a pool of healthy insurance customers off the exchanges, and a far sicker pool on the exchanges.
Technically, the subsidies ObamaCare provides on the exchanges ought to help the sicker customers afford those much more expensive plans. But the Senate version of TrumpCare already drastically reduces the generosity of those subsidies. And from a political standpoint, the subsidies are a lot harder to cut right now, when they go to a wide range of Americans buying coverage. If the subsidies become much more concentrated on just sick people, politicians could find them a lot easier to slash in the future.
This is all making moderate Republican senators like Susan Collins (Maine), Dean Heller (Nev.), Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Lisa Murkowski (Alaska), and others skittish. Remarkably though, McConnell is effectively giving these senators nothing on either the bill's astonishingly brutal Medicaid cuts, or on the broader structure of how the bill treats the exchanges. It does sound like this new version would scale back a few tax cuts for the wealthy, and pump extra money into stabilizing insurance markets and combating the opioid epidemic. But that's it.
Mostly, McConnell and his compatriots are trying to hold onto the moderates with brute peer pressure. "If you vote 'No' on this bill, it essentially is a vote for ObamaCare because that's what we're going to be left with," Sen. John Cornyn (R-Texas), the majority whip, recently told Fox News.
So how that's strategy going so far? Well, at the time of writing, Collins and Portman already balked publicly and McConnell's concessions to the right wing didn't seem to be enough to keep Paul on board.
The thing is, with Democrats uniformly opposed to TrumpCare, the Senate majority leader can only afford two dissenters. So if Paul, Collins, and Portman really do vote against it, then it's dead. And it might not even be that close. If Collins and Portman clearly state they're against it — Portman left himself some wiggle room here — then a whole bunch of other senators nervously sitting on the fence will bolt, as they won't be the senator who scuttled the whole project.
This may be why McConnell's plan seems to be built on sand. According to Politico, the Cruz-inspired amendment was placed in brackets in the bill's language, "indicating it is subject to change." Most likely, that's because the GOP is using a Senate procedural gambit called "reconciliation" to pass TrumpCare. It allows senators to avoid the filibuster and pass a bill with just a 51-vote majority. (With Vice President Mike Pence casting the tie-breaking 51st vote if need be.) But the bill has to restrict itself to changes that directly affect the budget, and the Cruz amendment is a regulatory change. The Senate parliamentarian could easily rule it out of bounds, which would send Cruz and Lee fleeing to the exits along with Paul.
Even more bizarrely, The Washington Post is reporting that McConnell tried to pacify the moderates by telling them the bill's deepest cuts to Medicaid probably won't ever happen — they don't take effect until after 2025, so Congress will probably find a way to avoid going through with them. Which probably doesn't inspire any confidence in how seriously McConnell takes this whole effort.
This brings us back to the Senate majority leader's reputation for legislative brilliance. He developed that reputation during the Obama years when he had one singular goal: prevent the president's agenda from passing. All McConnell had to do then was find ways to gum up the works in the Senate, while appearing to be the aggrieved party. Actually finding a compromise that can hold together a majority coalition to pass complex and massively consequential legislation is another matter entirely.
Rather than a mastermind, McConnell increasingly looks like a man who's just throwing up his hands and telling everyone what they want to hear — while praying it will all be over, one way or another, as soon as possible.
So much for the master strategist.