Today in Obamacare: the GOP’s new legislative strategy is really risky

The headlines about Republicans' repeal-and-replace woes are piling up. All eyes turn to President Donald Trump's speech Tuesday night, to see what he might say or do to kick-start the process.

So far, the president has been hesitant to give his full endorsement to the bill the House GOP leadership is cooking up. He could do that tonight, and if he does, Speaker Paul Ryan's staff would be overjoyed. He could also, once again, speak entirely in vague generalities and promise yet again that he'll release his own plan eventually. We'll see!

Overall, though, it's important to remember that while Trump has been a problem for the GOP's Obamacare repeal efforts, he hasn't been the problem. The underlying policy issues here are tremendously difficult and controversial, and there's little GOP consensus on many core matters.

That's why we're at a point where Republican leaders' strategy is essentially to try to ram something through and just "gamble that fellow GOP lawmakers won’t dare to block it," per a report by the Wall Street Journal's Louise Radnofsky, Kristina Peterson, and Stephanie Armour.

It's worth stepping back and thinking about how unusual this is. To pass Obamacare in the first place, Congress and President Barack Obama engaged in a months-long process in which reform was considered and amended by various committees and again on the floors of both chambers.

This process was time-consuming and felt maddening to many Democrats involved, but the goal was to let all the key stakeholder groups and every swing senator or Congress member air their concerns and to try to address them. That is how major legislation that can actually win majorities in both chambers is traditionally forged. This approach seems to be the opposite: moving quickly to a vote, and crossing fingers that the political system decides to go along with you.

The tyranny of the timeline

To get a better idea of why Republican leaders are pursuing this risky strategy, we need to take a look at the calendar and at congressional rules.

Republicans hold 52 Senate seats, so they can’t beat a filibuster on ordinary legislation without winning over at least eight Democrats.

Believing that to be unlikely, they’re trying to push their two big-ticket agenda items — health reform and tax reform — through the budget reconciliation process, for which only a simple Senate majority is necessary.

Here’s the problem: To actually use budget reconciliation, they have to jump through some procedural hoops and do things in a specific order. In their plan, the order was to be:

1. Pass one budget resolution with reconciliation instructions for health reform. (Done.)
2. Pass their health reform bill through the budget reconciliation process in both houses, and get it signed into law. (We're currently stuck here, still awaiting a bill.)
3. Pass a second budget resolution with reconciliation instructions for tax reform. (They had hoped to do this in April or May.)
4. Pass tax reform through the budget reconciliation process.

Now, an important reminder: This plan and timeline were initially developed for "repeal and delay" — the strategy that would have repealed Obamacare through reconciliation, set it to go into effect in a few years, and let Congress do the hard work of writing a replacement in the meantime.

Indeed, a major impetus for the repeal-and-delay strategy was that Republican leaders understood writing and passing an Obamacare replacement would be extremely difficult and take a really long time. The delay was meant to buy that time, and to let Congress get its health care reconciliation bill out of the way early so it could move on to tax reform.

Yet rank-and-file members of Congress panicked at the idea of ramming through repeal without a replacement being ready, and the president didn’t seem too keen on the idea either. Other Republicans accurately pointed out that the party would need Democratic support to pass the later replacement through normal order, and there was no guarantee they would get it.

So repeal and delay was scrapped. The new plan from GOP leaders, then, was to put as many elements of a replacement as they could in that one health reform reconciliation bill, and to hopefully, maybe, fix the rest later.

But then you get back to the initial reason leadership wanted the delay in the first place: Restructuring the US health care system is extremely difficult and time-consuming ("so complicated," as a leading politico recently put it).

And if you're facing calendar constraints and a crowded agenda, as Republicans are, you just don't have a lot of time to carry out the long, deliberative process necessary to craft something that can win broad support among Congress and stakeholders.

You either have to try to move quickly now or put the rest of the agenda on hold indefinitely to work on crafting a health reform bill with no guarantee of success. GOP leaders appear to be choosing the former.

Today’s health policy and politics reads

• “Trump concedes health law overhaul is 'unbelievably complex'”: “[National Economic Council Director Gary] Cohn and Jared Kushner, the president’s son-in-law and a senior adviser, have emerged as skeptics of the plan being developed by House Republicans, said the person briefed on the matter. ... The White House chief of staff, Reince Priebus, is more aligned with the House speaker, Paul D. Ryan, and the secretary of health and human services, Tom Price, who are championing the current repeal-and-replace bill.” —Robert Pear and Kate Kelly, New York Times
• "Here's a summary of House Republicans' leaked Obamacare draft”: “Some conservatives may therefore be concerned that the draft bill would retain the increased spending on adults in expansion states, extending in perpetuity the inequities caused by states that have used Obamacare’s 'free money' to raise Medicaid spending while sending Washington the tab.” —Christopher Jacobs, the Federalist
• "Obamacare gut check": "So, do Republicans believe anything they've been saying? Do they think Obamacare is an abomination, that kills jobs, drives up costs, erodes the quality of coverage, and stifles innovation? Do they believe Obamacare needs to be repealed and replaced, as they have insisted in every campaign they have run since 2010? If they do, they have a duty to follow through on the promises to which they owe their majorities, no matter the political risks." —Philip Klein, Washington Examiner
• "Trumpcare vs. Obamacare”: “Insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system is at stake. So are American lives.” —Atul Gawande, the New Yorker