Mediaboss Marketing

House Speaker Paul Ryan on May 10 in New Albany, Ohio. Ryan said last-minute changes to the American Health Care Act were narrow and insignificant.

Ty Wright/Getty Images

As the House was voting on the American Health Care Act on May 4, some Democratic members shouted WHERES THE SCORE? at their colleagues across the aisle. They were voting on a major piece of legislation without fully knowing its ramifications, since the Congressional Budget Office had yet to score its final version. Republicans choice to plow ahead anyway has earned them grief in interviews, at town halls, and even from some of their Republican colleagues in the Senate.

Jim Newell is a Slate staff writer.

House Republicans response to the public and their Senate peers was: Dont worry. The final, unscored amendments didnt really matter.

This is kind of a bogus attack from the left, House Speaker Paul Ryan said on ABCs This Week three days after the bill passed. He pointed out that the CBO had twice scored the AHCA and that the final amendmentintroduced by Rep. Fred Upton, which plugged another $8 billion into the billwas a mere three pages long. It takes you 30 seconds to read. The most recent CBO score, he said, showed that the bill was perfectly in compliance with the Senate budget rules, and the Upton amendment would not dramatically alter that score.

It was narrow changes to the bill, he said.

These were the talking points: The AHCA had been scored twice already, and the pesky three-page amendment tossed in at the end wouldnt make much of a difference. Ryan wasnt the only person to whom this talking point had been disseminated. Virginia Rep. Dave Brat, whose town hall I attended shortly after the bills passage, kept referring to the two-page amendment that would have an insignificant impact on the first CBO score. (The Upton amendment runs just a few lines onto a third page.)

Two problems with this spin: First, the Upton wasnt the only major amendment without a CBO score. The MacArthur amendment, which would allow states to opt out of certain Affordable Care Act regulations, also hadnt been scored.

And the idea that these amendments were narrow or insignificant, just because they were short in length, is belied by the enormous impact they had on the vote count. All but one of the conservative Freedom Caucus members voted for the AHCA after the MacArthur amendment was added; the Upton amendment gave leaders just enough moderate votes to bring the bill to the floor. Those 11 total pages delivered 30 or 40 fairly stubborn votes for a politically toxic bill.

But the best representation of how misleading this spin about the insignificance of a final CBO score was? House leaders, as Bloomberg first reported Thursday, wont even formally transmit the AHCA to the Senate until they see the final CBO score, because these teensy little amendments could force the House to change the bill and vote on it again. (Though the Senate claims to be writing its own health care bill, it still needs to use the House bill as the legislative vehicle for whatever those senators come up with.)

There are two ways that the CBO score, expected early next week, could force the House to change the bill. One would be traceable to that totally insignificant MacArthur amendment, another to those measly few pages of the Upton amendment.

The MacArthur amendment allows states to opt out of two critical regulations enacted under the ACA: community rating by health status, which requires insurers to charge the same prices to customers regardless of their medical history, and the requirement that qualifying health plans sold on the individual market cover a set of 10 essential health benefits. Its going to be difficult for the CBO to score the effects of these waivers, since itll have to use some educated guesswork to determine how many (and which) states might apply for them.

As I wrote in March, though, one of the side effects of eliminating these waivers would be increased government spending. If certain regulations are eliminated, insurers could offer bare-bones plans that induce healthier people to use the refundable tax credits the AHCA offers them. (Thats a generous explanation. My colleague Jordan Weissmann has noted how such deregulation pared with refundable tax credits is the recipe for the proliferation of a scam industry on taxpayers dime.) If the CBO projects millions more using the tax credits for skimpy insurance, it could blow through the AHCAs deficit reduction and make it a long-term deficit increaser, which isnt allowed under reconciliation rules. Should the CBO make that determination, the Senate wouldnt be able to act on the bill.

The bill doesnt just have to be a long-term deficit reducer overall. Each committee of jurisdiction involved in writing the reconciliation billthe finance and health policy committees in the House and Senatehas to save at least $1 billion in its contribution to the legislation. So even if the finance portion of the AHCA was to save tens of billions of dollars, the health portion would still have to find its own $1 billion in savings.

The CBO could show that the health committees contribution falls short. Voxs Dylan Scott spoke to a budget expert at the Committee for a Responsible Federal Budget who estimated that provisions under the health committees jurisdiction could cost $6 billion. The Upton amendment, ostensibly under the health committees jurisdiction, added $8 billion in spending to the bill.

Republican aides arent sweating the problems too much. A Senate GOP aide described the holdup on the transfer to me as S.O.P. [standard operating procedure] on reconciliation bills that are coming from the House to the Senate.

There are lots of ways to fix issues that come up before the Senate considers the legislation, the aide added, but again, we wont know exactly what they are until the CBO score comes out. But again, not worried.

Top Comment

AHCA The Sequel - Saving Ryan's Privates! More...

The issue here is not that the House couldnt fix problems that arise from the CBO score. Its that its a little embarrassing that problems would arise from the CBO score, after leaders had insisted that the late amendments were but narrow, insignificant changes. (They just magically got 40 of their colleagues to vote for it, thats all.) The MacArthur amendment, especially, makes such significant changes to public policy that it could eat up the previous versions comfortable cushion of savings. Its a big enough deal that leaders are holding onto the bill until they see the CBO score. But it wasnt deemed important enough for citizens to see the score before their representatives voted on it.

If the House did have to rework the legislation and call it up for a second vote, it would put the vulnerable Republicans who had to be dragged kicking and screaming the first time in an even worse position. If they didnt vote for it a second time, Democrats would still blast them for having voted for a bill separating 24 million people from their health care before knowing all of its dastardly effects. If they did vote for the second version, theyd be blasted for voting for a world-historically toxic bill twice. A revote may be only a narrow, worst-case scenario. That its a possibility at all is lesson enough in waiting for all of the information to come in. Well see if Senate Republicans heed that lesson when its their turn to vote.

More:
House Republicans May Have to Vote on Trumpcare Again - Slate Magazine