Health care score is Republicans 1, Americans 0: Andy Slavitt

Republicans celebrated on TV with cheers and a Rose Garden ceremony, but many Americans reacted with disbelief and outrage when the House voted to dramatically scale back access to health care for millions. The narrow party line vote, and the public high-fiving by Congress and the White House, comes despite polls showing that by large majorities, Americans want to keep and repair Obamacare — not turn back coverage for millions of families as House Republicans voted to do.

There is little support for repealing the Affordable Care Act and even less for the American Health Care Act passed by the House. Only 17% of the public favored a previous similar version and the new one was uniformly opposed by patient groups and care providers. It raises premiums, guts the vital Medicaid program and, while President Trump attempted to cloud the question in recent interviews, it would break a major promise of his by removing the federal ban on insurance discrimination against people with pre-existing conditions.

My Twitter feed is buzzing with stories from parents of children with disabilities and lifelong chronic illnesses. If there’s anyone who is an expert on the details of the health care system, it’s the parent of a sick child. A pediatrician relayed to me the three horrors of the Republican bill from her standpoint: patients being segregated into a high-risk pool, the reintroduction of lifetime caps on insurance, and what a pre-existing condition means in the real world to her young patients — and to a parent like her. Her own son needed heart surgery that cost more than $1 million as a newborn.

How could there be such a disconnect between the state of our politics and the real world? And what are the prospects for the Senate to correct that?

Sometimes, the political forces just outweigh the real-world consequences. The fact that the majority party cast a party-line vote should be a surprise to no one. What’s more notable was the closeness of the vote, the failed first effort, the amount of arm-twisting, and the immediate distancing even of members who voted for the bill. Who can remember the last time a member issued a statement saying “No, I don’t like it” for a bill he just voted for, as Republican Mario Diaz-Balart of Florida did?

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The internal GOP politics were too strong for Americans opposed to the bill to overcome, even though House Republicans could pay a price. The Cook Political Report now puts 197 of the 241 GOP-held districts in the safe category (six fewer than before the health vote) and moved an additional 14 seats to riskier ratings after the vote. When House Speaker Paul Ryan made his closing appeal to rank-and-file members, he focused on the political consequences of not voting to repeal the ACA. The threat was entirely from a more conservative primary challenger, not the general election. In case the message wasn’t heard, the president reinforced it with not so veiled threats to back primary opponents of those who wouldn’t get on board.

Republicans representing swing districts or those won by Hillary Clinton were in a tougher spot. They have to pay closer attention to the needs of their district, but they also need to keep money in mind. Rep. Erik Paulsen spent nearly $6 million to defend his Minnesota seat in 2016, and it will cost more in 2018. That kind of money is hard to raise locally and only comes with support from party leadership and big donors such as the pharmaceutical and medical device industries. And so one by one, reluctant swing-district lawmakers were picked off. As the real world needs become secondary, most GOP lawmakers are choosing to avoid facing constituents directly in town halls.

You can’t blame them. As Sen. Lindsey Graham, R-S.C., tweeted, the bill was "finalized yesterday, has not been scored, amendments not allowed, and three hours final debate." For a bill that would affect virtually every American if it becomes law, the sponsors knew well that exposure to details — including a Congressional Budget Office “score” on its cost and consequences — wouldn't help their cause.

These games matter in the real world. Even in the few overnight hours between when the text of the bill was released and when it passed, hidden items were uncovered that could harm victims of domestic violence, special education and protections for employer-based coverage. It turns out that even a fund billed as assisting people with pre-existing conditions can be used to reduce costs for the healthy. More time with these and other discoveries would have risked real-world concerns eclipsing Washington deal-making. The games betray a disrespect for the American voter that runs deep with the House leadership.

Fortunately, a number of senators are expressing caution. Since Republicans only have two votes to spare to pass anything, the Senate is likely to toss the House bill aside and begin with another bill entirely. And Senate rules mean the provisions that allow discrimination against people with pre-existing conditions, the ones that won over conservative House members, might not even be considered.

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Senate Majority Leader Mitch McConnell has an important choice in front of him. He can choose to correct the House’s errors and produce a bill that makes life better, not worse, for Americans — among them hundreds of thousands in his home state of Kentucky who would lose coverage under the House's Medicaid cuts. He could also help Trump keep three promises he has made: that no American would lose coverage, that premiums would go down, and that Americans with pre-existing conditions would continue to be protected from discrimination.

The House bill did not do any of those. That it did not, and Trump claims it does, signals that he is likely to sign whatever bill comes across his desk. It puts the Senate in the best position to reverse course and honor these promises.

As we learned last November, eventually real-world concerns can bring political change and elections once thought to be safe aren’t any longer. Frustrations over being ignored are high. For many Americans, the 2018 midterm elections began with Thursday’s vote.

Andy Slavitt, a member of USA TODAY's Board of Contributors, is a former health care industry executive who was acting administrator for the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt 

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