Trump sets up high-stakes healthcare gamble in House

Trump With Hand Raised
The choice to set up a high-stakes vote amid doubts that the American Health Care Act can pass is politically risky—and is likely to only compound the uncertainty facing the health insurance industry.

After the House failed to vote on a sweeping healthcare overhaul Thursday as planned, President Donald Trump set up an ultimatum for the body: Vote Friday to pass the bill, or keep the Affordable Care Act intact.

At a meeting of House Republicans on Thursday night, White House Budget Director Mick Mulvaney told members that Trump was finished negotiating and ready to move on, the Wall Street Journal reported.

House Speaker Paul Ryan was also on board with a Friday vote, telling reporters in brief remarks Thursday night that “We have been promising the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families. And tomorrow we’re proceeding.”

And Trump himself tweeted his support Friday:

The choice to set up a high-stakes vote amid doubts that the American Health Care Act can pass is politically risky—and is likely to only compound the uncertainty facing the health insurance industry, Julius Hobson, a senior policy adviser with the Washington, D.C.-based firm Polsinelli, said in an interview.

Uncertainty, he said, is “the one thing that business doesn’t like,” but it’s exactly what insurers and the rest of the healthcare industry are facing given the fact that they don’t know what Congress is going to do.

“I would venture to guess that they’ll start pulling out of the individual market because of that kind of uncertainty,” he said.

If today’s vote fails, Hobson predicted that the Trump administration’s approach to the ACA would be to “try to strangle it to death administratively”—and that effort could very well succeed. The IRS, he pointed out, is already not enforcing rules requiring those who don’t comply with the individual and employer mandates to pay a penalty.

But on the other hand, if the bill is able to pass both chambers of Congress and go to Trump’s desk to be signed, insurers might be pleased by the removal of the ACA’s essential health benefits requirements, according to Hobson.

RELATED: With fate of GOP healthcare bill unclear, essential health benefits on chopping block

Indeed, an amendment introduced Thursday night would let states determine essential health benefits—rather than the federal government—beginning in 2018, Axios reported.

But removing the mandate for a core set of essential benefits also means that people with preexisting conditions will pay more for the coverage that they need, Hobson pointed out. Health policy expert Tim Jost held a similar view, writing in a Health Affairs Blog post that "plans might still be prohibited from excluding pre-existing conditions or engaging in health status underwriting, but could accomplish the same goal through defining the services they cover."

Looking ahead, Hobson said that even if the bill passes in the House on Friday, it may be amended in the Senate in a way that makes it unpalatable to the same House conservatives who fought its passage initially—making it difficult to reconcile the two versions.

“We’re watching the speaker ask members to walk the plank on a bill that they don’t like, that conservatives don’t see as being conservative enough,” he said. “And if the Senate is able to pass something, it will be considerably to the left of what the House does, and when it comes back to the House, you’ll be asking House members, ‘walk the plank again on something that’s even more liberal.’”

At around 10:30 Friday morning, the House began to vote on the “manager’s amendments” introduced earlier this week amending the AHCA, as well as last-minute additions agreed upon Thursday night. 

1:50 p.m. update:

White House Press Secretary Sean Spicer confirmed Thursday afternoon that Trump and Ryan were meeting to discuss the current vote count. 

Spicer was generally unwilling to speculate about what will happen if the vote fails, instead saying a vote on the bill was planned for 3:30 in the House and expressing optimism that it will pass.

Either way, the president and his team have "left everything on the field" when it came to working to address members' concerns, Spicer said. Members now have the choice whether to keep the ACA intact or keep their campaign promises to repeal it, he added, saying, “right now, this is the choice that will save the system."