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Why the Trumpcare vote could hurt Republicans no matter how they vote

President Trump didn't sugarcoat the political consequences of a vote against the House Obamacare replacement bill on Thursday. "I honestly think many of you will lose your seats in 2018 if you don't get this done," he told House Republicans, per a source in the room.

True enough, but these members also could lose their seats and the House majority if they do vote to pass the bill currently being considered. So they're left with a terrible choice: Vote against Obamacare repeal after campaigning on repeal for seven years, or vote to cover 24 million fewer people and potentially raise premiums for senior citizens.

We asked more than a dozen Republicans, Democrats and health-care industry officials which is the better choice, and unsurprisingly, we came up with a mixed verdict. But there was a consensus on these points:

  • Neither choice is enviable.
  • It's not every day — or maybe ever — that the far-right, the left and nearly every health care group are on the same page. But these three different factions all oppose the House bill. It's mainly establishment Republicans that support it.

Republican leaders reject the idea that there's a downside to the vote, of course. They insist they're on a rescue mission to save the Affordable Care Act marketplaces from collapse (even though independent analysts don't think the infamous premium hikes this year would have been repeated).

Meantime, Democrats feel like they've won the lottery for 2018. "For (Republicans) who vote against it, they have to worry about being primaried. For those who supported it, the town halls may only be a taste of what's to come," said Jim Manley, a former aide to Harry Reid.

The view from the health care industry: Passing the current version of Obamacare repeal-and-replace is worse than getting nothing done. Hospitals, doctors and most health insurance companies hate the bill. The American Hospital Association has already run ads urging people to oppose it. The Alliance of Community Health Plans, a lobbying group for not-for-profit insurers, suggested Republicans start over.

"It's very hard to say with a straight face this bill is good for the health care system by any objective measure," said Billy Wynne, a consultant and former Senate Finance Committee counsel. Larry Levitt of the Kaiser Family Foundation warned: "When every health care industry group is aligned against you, it's awfully hard to get something through."

Hospitals and doctors believe the bill would decimate them and create some insurmountable headlines:

  • Less coverage for children. Dr. Andrew Racine, a pediatrician and chief medical officer of Montefiore Health System in the Bronx, said the GOP bill would undo the work of getting more kids access to care. Roughly 95% of children have some kind of health insurance now, due largely to Medicaid expansion.
  • Bad for hospitals. Mike Abrams, CEO of the Ohio Hospital Association, has met with Sen. Rob Portman and others to show the opposition is policy-driven. If the current bill passes, "50 hospitals out of our 220 are going to be in a very precarious economic situation." That means possible layoffs, closure of low-margin services like baby deliveries or closure of the entire hospital.

The Democratic view: It's bad both ways, but probably worse to vote for it. They say the policy is horrible, and Republicans are likely stripping coverage from the people who elect them — older, rural white people. The ads about age taxes and sick people losing coverage are basically going to write themselves over the next year and a half.

The view from far-right groups: It's worse to vote for this bill — which they're dubbing Obamacare Lite — than against it because it'll make Obamacare's problems worse. An increase in premiums and deductibles over the next couple years will be particularly damning. And they're not going to drop this.

  • James Davis, a spokesman for the Koch network: If Republicans "don't move forward with a plan we can get behind, it's hard for us to stand with them...If we are not standing with you, it can have a tremendous political impact...look at Kelly Ayotte." (The New Hampshire senator lost their support and then lost her seat by a very narrow margin.)

The view from establishment Republicans: It's worse to vote against this bill because they will be breaking promises and losing the base. This, ultimately, is what's causing Trump, House Speaker Paul Ryan and Majority Leader Mitch McConnell to force their members to take such a difficult vote.

  • Chris Condeluci, a former GOP Finance Committee aide, said a no vote will cause the Republican base and Trump voters to view the Republicans "as weak and disorganized."
  • Rodney Whitlock, another former GOP Finance aide: "With the initial score showing 24 [million] people losing coverage, the fact that the House is moving forward shows they are more concerned about the politics of proving they are repealing the ACA than the policy impact of the bill."
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