The One Obamacare Provision That Could Blow Up A Republican Repeal

WASHINGTON As Republicans stake out positions on what an Obamacare repeal needs to look like to secure their vote, one popular component of the 2010 health care law is threatening to sink the GOP’s entire repeal effort: the Medicaid expansion.

House conservatives are adamant that any repeal bill take away the expansion, which increased free or low-cost Medicaid coverage for people making less than 133 percent of the federal poverty level about $16,000 a year for a single person. The House Freedom Caucus voted Monday night to oppose any repeal bill that was not as aggressive as the one the House and Senate passed in 2015. That bill gutted the Medicaid expansion.

But now that lawmakers are “playing with live rounds this time,” in the words of Rep. Charlie Dent (R-Pa.), some Republicans are showing reluctance to actually get rid of a program that has won over a number of Republican governors and covers more than 14 million people.

“That genie is out of the bottle,” Dent said of the Medicaid expansion. “And I guess I would say to you too that we have to be careful that we don’t go pulling the rug out from under people.”

Dent told The Huffington Post on Wednesday that he didn’t know if there were 218 votes in the House for a repeal bill that gets rid of the Medicaid expansion, and he said most Republicans in his roughly 50-member moderate Tuesday Group, of which Dent is the chairman, believe that an Obamacare repeal would need to be coupled simultaneously with a replacement bill and that Republicans would have to think carefully about what they do for Medicaid.

“A lot of Republicans who represent expansion states are going to handle this Medicaid issue very delicately, and they’re not going to be taking an ideological doctrinaire position,” Dent said.

If Republicans really do vote their district, that could be a problem for GOP leaders.

There are number of states that greatly benefit from the expansion states that voted for President Donald Trump and have heavy Republican representation in Congress, including Kentucky, Arkansas and West Virginia. The key for GOP leaders is to convince governors that gutting the expansion is in their interest, even when the federal government is paying at least 90 percent of the costs to cover their residents.

“We’re going to be listening to the governor and the Kentucky general assembly,” freshman Rep. James Comer (R-Ky.) said Wednesday. Kentucky’s uninsured rate fell by more than 12 percentage points  under the Affordable Care Act the largest drop of any state in the nation. The state’s Republican governor, Matt Bevin, ran as an opponent of Obamacare. But after he was elected, he went back on a promise to gut the Medicaid expansion.

But don’t necessarily count on the Republicans whose districts make out on the deal to preserve it. “The Medicaid expansion is not sustainable,” Comer said. Nearly 10 percent of the people in his district  are covered by the program.

The dynamic in Congress is that conservatives are intent on removing the expansion, and moderates are somewhat determined to keep it or at least some form of it. Leaders have to either roll one side of the conference or somehow split the difference. Either way, finding 218 votes in the House and, perhaps even more challenging, 50 votes in the Senate might not be possible with the different demands that Republicans have on Obamacare.

Asked how leaders could fulfill the Freedom Caucus requirement of removing the Medicaid expansion and still please moderates who want to preserve it, Rep. Greg Walden (R-Ore.), the chairman of the House committee with jurisdiction over Medicaid, told HuffPost on Wednesday that he thought Republicans would be able to write a bill that accomplishes more than the 2015 repeal bill and would “actually get to entitlement reform of Medicaid.”

But would Republicans be preserving the Medicaid expansion?

“You’ll see it when we roll it out,” Walden said, “but the long and short of it is we have a great opportunity to reform Medicaid, a positive way to give flexibility to states, to bend the cost curve down.”

If that sounds like Republicans are going to cut the expansion, it probably should.

The “Better Way” agenda that House Republicans put forth would end the expansion and either block-grant Medicaid or dish out money on a per capita basis. That would almost certainly please conservatives, but it would also test the resolve of moderates who want to preserve the program.

It’s just that the moderates have so far taken a softer line on what they need to support an Obamacare repeal.

House Appropriations Chairman Rodney Frelinghuysen (R-N.J.) noted on Wednesday that his state has benefited from the expansion, and he said he would have to look carefully at the repeal bill and what it does to Medicaid before committing his vote. “Obviously there has to be some sort of resolution,” he said. But that didn’t necessarily mean he would vote against something that repeals the expansion.

Rep. Peter Roskam (R-Ill.) noted he was “getting a lot of feedback” from his district on Obamacare protesters have zeroed in on Roskam as a vulnerable Republican and that he was listening carefully and looking to make a “smooth transition from the status quo to a new approach.”

Again, even in a district that went for Democratic presidential nominee Hillary Clinton , Roskam isn’t vowing to protect low-income people who are now getting health insurance free or at a very small cost. Even the moderates who are taking a more aggressive tack are putting their trust in leaders to eventually come up with something that doesn’t devastate their constituents. 

”I am confident that leadership recognizes there has to be some acknowledgment of the states that expanded Medicaid,” said Rep. Leonard Lance (R-N.J.), one of the most likely candidates to vote against the GOP’s repeal plan.

And for every Leonard Lance, there are 10 House Republicans who are dedicated to repeal no matter what. As Rep. John Shimkus (R-Ill.) said Wednesday, “If it’s a repeal, I’m there.”

The Medicaid expansion problem is trickiest in the Senate, where leadership can stand to lose only two votes and still pass a reconciliation bill repealing Obamacare, assuming every Democrat votes against it.

Sen. Mike Rounds (R-S.D.) told reporters on Wednesday that he saw problems in reaching a majority in the Senate if Republicans repealed the Medicaid expansion. 

“The problem is you also have to have all of the Republican governors supporting whatever you do or you’re not going to get the support of 51 folks stepping in,” Rounds said. “Realize we need 51 votes on this, and if you don’t treat your states appropriately, you’re probably not going to get your 51 votes.”

And if a repeal vote looks dead in the Senate, it would certainly scare Republicans in the House.

The whole repeal-and-replace gambit relies on getting Republicans with competing interests on board, even if it’s not in their constituents’ interests, with the distant promise that leaders can come up with something better. The emerging line from Republicans is that people who currently get nearly free health care under the Medicaid expansion will like having more options for insurance. 

But those people will also be paying exorbitantly more for that coverage, and there’s hardly any way for Republicans to mask that.

If moderates have ever had a chance to shape the Obamacare discussion, this is the moment. Which is why conservatives have so forcefully signaled that they won’t support any repeal bill preserving the Medicaid expansion. Their goal is to close off the possibility that a repeal bill keeping those Medicaid provisions could ever pass, leaving a measure that blows up the expansion as the only option for leaders.

The question is why GOP moderates are so timid about signaling they won’t go along with a bill that guts the program. Dent is posturing that there are vote problems if Republicans repeal the expansion, but at this point, it’s just posturing.

If moderates got serious about opposing a bill touching the Medicaid program, and if conservatives were truly serious about opposing a bill that doesn’t touch it, an Obamacare repeal might be impossible.

Asked if the repeal would be in danger if Dent really had a majority of the Tuesday Group committed to preserving the Medicaid expansion, House Freedom Caucus Chairman Mark Meadows (R-N.C.) told HuffPost that it would indeed be a problem.

“If he has more than 25 votes that are that way, yes, it’s trouble.”

Huffington Post reporter Jeffrey Young contributed to this report.