The only thing surprising about yesterday's partisan, razor-thin vote to gut Obamacare was that it took so long.
As I noted two months ago, well before the failure of the first iteration of the American Health Care Act, President Donald Trump and House Speaker Paul Ryan are playing the long game. All they needed in the House was a bill—any bill—so they could throw the legislation into the more moderate Senate.
They had to appease the GOP's ultra-right wing to get the votes they needed. The AHCA that passed yesterday does that in spades.
Forget all the palaver about pre-existing conditions that dominated the political debate and the headlines. The Senate will never allow that failed policy to see the light of day.
But what the GOP Senate majority could unite around is turning Medicaid into capped block grants to the states. They also would support turning the insurance exchange program from one based on subsidies to one based on tax credits.
Ending the service guarantees in Medicaid is the main reason why the GOP wants an immediate repeal of Obamacare. The GOP needs the more than $800 billion it will "save" by turning the program into block grants to the states so they have the fiscal capacity under Congressional Budget Office scoring rules to give a tax break to corporations and the well-to-do.
Of course, turning Medicaid into block grants doesn't save money. It merely transfers the responsibility for poor peoples' healthcare to the states. Unless they're willing to raise taxes considerably—not likely—they will be forced to slash both Medicaid availability and provider rates that are already well below the actual cost of care.
The endgame—something that should be anathema to anyone who entered healthcare because of their humanitarian impulse to serve people—will be a two-tier healthcare system. There will be one for people with employer-based coverage and another for anyone dependent on the government.
(The GOP would do the same to Medicare, but that's a harder lift. It's a lot easier to pick on the poor than it is to pick on a program that serves everyone.)
The politics of the AHCA from here are fairly predictable. There will be a CBO score. The Senate, unlike the House, will hold hearings. This will allow Democrats to highlight the grievous shortcomings in the bill.
The eventual Senate version of the bill will give Republican moderates such as Susan Collins of Maine and Rob Portman of Ohio big "wins" such as protecting people with pre-existing conditions from known-to-fail high-risk pools. The bill will pass and go to conference.
Will the Freedom Caucus give Senate Majority Leader Mitch McConnell what he needs to get a conference-reported bill through the Senate? It's entirely possible that they can be persuaded to go along with substituting tax credits for subsidies in the Obamacare insurance expansion as long as they get the big win of turning Medicaid into block grants. That will give every GOP-controlled state legislature in the country the opportunity to tinker with the program and reduce benefits for the poor.
The electoral dynamics over the next year entirely favors the Republicans. They control both houses of Congress. They control the White House. And 25 of the 34 Senate seats up for grabs in 2018 are held by Democrats.
If the Republicans can get a bill to President Trump's desk by next spring, it won't matter if Democrats win back the House, or, for that matter, if they get a stunning upset and win control of the Senate.
The threat of a Trump veto means the replacement bill will be on a glide path to implementation—probably in 2021 so that the public won't be subjected to its worst effects before the next presidential election.
