ROBERT COSTA: The health care debate under the microscope. I’m Robert Costa. We examine what’s inside the Senate Republicans’ rewrite of the Affordable Care Act, tonight on Washington Week.
SENATE MAJORITY LEADER MITCH MCCONNELL: (From video.) We agreed on the need to free Americans from Obamacare’s mandates. We’ll repeal the individual mandate so Americans are no longer forced to buy insurance they don’t need or can’t afford.
MR. COSTA: Senate Republicans rolled out their health care plan after weeks of closely guarded discussions. Democrats argue the bill is even worse than the version that came out of the House.
SENATE MINORITY LEADER CHARLES SCHUMER (D-NY): (From video.) Simply put, this bill will result in higher costs, less care, and millions of Americans will lose their health insurance.
MR. COSTA: But a revolt by a handful of Republicans could put this newest bill in jeopardy.
SENATOR TED CRUZ (R-TX): (From video.) We need common-sense reforms in the bill that lower the cost of premiums.
SENATOR RAND PAUL (R-KY): (From video.) We also need to negotiate over what’s good, what’s bad, and what we can get in the bill to make it better.
MR. COSTA: President Trump remains optimistic there is room for compromise.
PRESIDENT DONALD TRUMP: (From video.) We will hopefully get something done, and it’ll be something with heart and very meaningful.
MR. COSTA: We look at the real costs and benefits of this latest prescription. Plus, the blame game: how this week’s special election in Georgia is reverberating on Capitol Hill, raising questions about the leadership of the Democratic Party.
We explore it all with Susan Davis of NPR, Sarah Kliff of Vox, Philip Rucker of The Washington Post, and Kelly O’Donnell of NBC News.
ANNOUNCER: Celebrating 50 years, this is Washington Week. Once again, live from Washington, moderator Robert Costa.
MR. COSTA: Good evening. The Senate Republicans’ plan to dismantle the Affordable Care Act continues to get pushback, not just from Democrats but from fellow Republicans. Senator Majority Leader Mitch McConnell stands by the bill, saying it will repeal most of President Obama’s signature health care law, reduce government-paid health care and return power to states. Democrats, well, they insist the GOP plan will increase premiums and take health care away from millions of elderly and low-income Americans.
Complicating matters for McConnell today are five Republican senators, Ted Cruz, Ron Johnson, Dean Heller, Mike Lee and Rand Paul, four of whom immediately rejected the bill, saying it does not go far enough to gut Obamacare.
SEN. PAUL: (From video.) We can do better than this, and my hope is not to defeat the bill but to make the bill better.
MR. COSTA: Moderate Dean Heller of Nevada was the latest to speak out against the Senate bill. At this point it seems no one seems to love it. But as Republican Senator Pat Roberts of Kansas said, the Senate bill was not the best possible bill but the best bill possible.
We’re looking at a real challenge for Senate Majority Leader Mitch McConnell. What’s he going to do, Kelly, to close it?
KELLY O’DONNELL: Well, first of all, he’s going to work all weekend, and so will all the people on the team. The phone lines will be burning up. The personal meetings will be happening. And they’re looking for ways to find some things that can induce some of these members.
One word to be watching for: opioid. Opioid money is an attractive inducement to some of the members. I’m thinking of a Rob Portman of Ohio, for example, who could be brought along; Shelley Moore Capito of West Virginia – that could be helpful.
In addition to this, low-key Donald Trump. I know I may never say that again, but a more subtle approach where the president is helping but a bit under the radar, really letting Mitch McConnell run this.
But it’s very high stakes. I haven’t talked to anyone who will say it will pass. But they’re going to work like heck to get there. And they think that if they don’t do this, it’s a major failure for the party. The House did act, however their process was, however messy and unpopular their bill is; Senate Republicans feel immense pressure that they have to do something. And we’ve got a recess coming, when they’ll have some judgment at home. But if they could get it done, they can then move on to some other things that might be more popular to build up some momentum for those that are up for re-election and may be vulnerable.
SUSAN DAVIS: Mitch McConnell has going for him what House Speaker Paul Ryan ultimately had going for him is that every single Republican in his caucus campaigned and won their elections saying they were going to do this. And to Senator Roberts’ point, they don’t love this bill. I mean, there is something in this bill for every Republican to have a problem with. But this is the repeal-and-replace bill that they have.
And I think the way you saw the House bill come together, there is just a tremendous amount of pressure, not only from the party’s base, but as you said, I think we underestimate how much the White House wants a bill because they have had such a light touch in the policy shaping of it. And the message that I hear from Senate Republicans is the White House is telling them, you know, we just want a bill. And I don’t think we can underestimate the power of the presidency putting the pressure on his own party in power in Congress to deliver on the single unifying campaign promise of the Republican Party for the better part of the last decade.
MR. COSTA: Kelly, you said it was low-key on the White House’s end. And Phil, you’re the bureau chief for the Post. What’s the story here with the president’s involvement with this health care bill? We know that he at one point said that he – the bill was mean. That was the word he used in a private meeting. But now he was making a call, I was told, on Thursday to Senator Cruz trying to get him to come along. Is there a real intense effort to get it passed?
PHILIP RUCKER: That’s right. Well, one thing is the president is impatient. This is not a man known to want to wait for things. He’s impatient about the legislative process. He wants a victory. He’s been in office for five months. There is no signature legislation yet. This could be it. But he’s taking a backseat to Mitch McConnell. He knows that he’s not going to be effective persuading some of these more moderate Republican senators to come on board. So he’s stepping back. But he’s working with the more conservative members quietly on the phone to try to make a deal happen. He doesn't care so much about the details of the bill; he just wants something to sign. But Sean Spicer today, the press secretary, said at White House that, look, the president likes the Senate version better than the House version. He thought the House version ultimately was too mean, too hard on poor people, especially on the Medicaid funding. He thinks the Senate one is a better pill, so to speak.
MR. COSTA: Let’s talk about some of the specifics here because there are challenges from the center, challenges on the right. And this bill, the Senate version, it eliminates the individual insurance mandate and Obamacare taxes on the wealthy, slashes federal funds for Medicare and phases out the expansion of Medicaid. It allows states to waive a federal mandate on essential health benefits, raising questions, of course, about coverage for preexisting conditions. It shrinks Obamacare subsidies to pay for premiums. And what remains unchanged is young people could stay on their parents’ plan until age 26.
Sarah, it’s great to have you here, and you’re such an expert on health care. What everyone’s wondering is, if this Senate bill passes and it becomes law, what does it mean for people who rely on the Affordable Care Act?
SARAH KLIFF: So it means a lot of changes. This would really overhaul the way that health care works for this group of about 20 million people. These are generally people who don’t get health insurance at work, who are getting insurance through Medicaid, through the individual market.
Folks on Medicaid would probably notice the biggest change. You would see the Medicaid expansion phasing out starting in 2021; by 2024 that program would be gone. And that covers an estimated about 12 or so million low-income Americans, people who are earning less than $15,000.
People in the rest of the Medicaid program would notice some very big changes as well. One of the big things this does that really isn’t about Obamacare is it just rejiggers how the Medicaid program is funded. Right now the federal government has an open-ended funding commitment. Whatever the bills of Medicaid enrollees are, the government will help pay them. Under this bill, the bills would be capped, essentially, that for each person, you would get a lump sum of money, and you would do your best you could as a state to cover that person for that set amount of money. So that’d be a big change. And I think the concerns you hear Democrats raising are that this lump sum of money, it wouldn’t be nearly enough to cover the people who are on Medicaid. It would grow much slower than the Medicaid program typically grows. So that’s the Medicaid bucket of changes.
You also have some big changes, like you mentioned, in the individual market, where people would see much smaller tax credits, much less help from the government, and they would generally see skimpier health insurance plans. So one of the things that a lot of Obamacare enrollees I talked to, they complain about their high deductibles, that they really don’t like these deductibles. You’ve heard Senate Majority Leader Mitch McConnell talk about these high deductibles. This plan, it seems pretty clear the deductibles would go up, that people would have to pay more out of pocket before getting to their benefits.
MR. COSTA: So you’re saying – so often this bill is talked about as maybe a tax cut for the wealthy, it’s a bill to overhaul Obamacare. But what you’re really saying is it’s also an overhaul of Medicaid, a program that’s been around for decades.
MS. KLIFF: Yeah, this would – I don’t think it’s underestimation to say this would be the biggest change to Medicaid since it were created in 1965. It would really change this relationship that the government has had with Medicaid, where it says no matter what the medical bills are we’ll kick in a certain portion, states will kick in the rest. It’ll say here’s your amount of money and you have to work within those means. It would be a pretty unprecedented rollback of welfare programs. Usually one of the things we see here in the United States and abroad is that it is very hard to roll back benefits once they go out. And I think that’s been a key challenge that Republicans have dealt with in this debate, is that there are 20 million or so people relying on Obamacare. It is very, very hard to take something away once it has been given out.
MR. COSTA: Phil, you were on the campaign trail with President Trump, and you heard him so many times say he doesn’t want to go after Medicare, he doesn’t want to go after Medicaid. Now he seems to be rallying behind this more ideological agenda of congressional Republicans on health care. Why?
MR. RUCKER: Well, he wants a win. He wants to be able to do what he said he would do, which is change – get rid of Obamacare and change it. He says it’s a disaster again and again, so he wants the change there. But it’s really risky for him. He was elected on the backs of, you know, working-class people in states like Michigan, Wisconsin, Pennsylvania. You know, he had so much support in West Virginia. And these are states that are really going to be probably pretty battered by these changes to the market.
MS. O’DONNELL: And where there is policy, there’s also process, and it’s not as sexy to talk about. But one of the issues Republicans have is they only have 52 votes. They can only spare two, and they have the vice president to come in and break a tie. When the Affordable Care Act was put into place, Democrats had 60 votes. They had a lot more flexibility. And under reconciliation, which is a term used to describe this kind of legislation, all of the specifics are so narrow. If we watch courtroom dramas, you know that sometimes there are the rules of evidence that come in, and only that can argue the case. Well, for Republicans, they have to thread a needle of very difficult rules, and that is part of where it’s tough because they can’t necessarily bring in some of the things that people might want to bring them along because they have to fulfill certain requirements under the legislation. It’s a boring part of it, but it is the underpinning of why this is so hard.
MR. COSTA: Sue, what’s your read on who determines how this bill actually shakes out in the coming days? Is it the moderates? Is it Heller? Is it Murkowski? Or is it the conservatives, like Cruz?
MS. DAVIS: That’s a great question, because we saw today Dean Heller from Nevada is the only Republican in a blue state up for reelection next year, was probably – so far come out the harshest against it, although he gave himself a little wiggle room to get to a yes in the end. Remember, this bill still has to go through a pretty tremendous amendment process in the Senate.
You know, on the one hand you have these conservatives who just say this is Obamacare lite, this is not what we came here to do. And then you have moderates like Susan Collins of Maine, Lisa Murkowski of Alaska, who have a whole other set of issues with this bill, including its proposal to block Medicaid reimbursements to Planned Parenthood for a year. I mean, that’s a big issue in states like Alaska. So how McConnell skins that cat where you get Ted Cruz and Susan Collins to hold hands and vote for this bill, it is not easy. But I also just think the mood is that they’re not underestimating McConnell, and how much of this right now is a little bit of political theater? How much do conservatives have to say I don’t really like the bill the way it is, maybe give them a couple amendments.
MS. O’DONNELL: Oh, built in, totally built in.
MS. DAVIS: They get to say they improved the bill, and they get to yes in the end.
MR. COSTA: Sarah, what about preexisting conditions? This was the big hangup when it was being written in the House. How does it look in the Senate?
MS. KLIFF: Yeah, so it is different from the House bill in that way. It would not allow insurance companies to deny anyone with preexisting conditions, to treat them differently, but it still creates a market that isn’t exactly friendly to people who have serious health conditions, and it has to do with those essential health benefits you mentioned earlier. Under the Senate bill, states could apply for a waiver from those benefits. Those cover things like maternity care, mental health services, prescription drugs. These are things that were often left out in the individual market because they can be quite expensive to cover. So this can, essentially, be a backdoor way of getting the sick people out of the insurance market. Because let’s say you have a health insurance plan that doesn’t cover cancer treatment or doesn’t cover certain prescription drugs. It technically accepts everybody, so it is certainly true that these plans do not discriminate on preexisting conditions, but it’s also not attractive to someone who actually needs to use a lot of health care. So it is both true that Republicans can say, you know, our plan treats people with preexisting conditions the exact same, and Democrats can say you’re creating a market that is worse for sick people.
MR. COSTA: Phil, you cover President Obama as well. He’s weighed in with a forceful reaction to this Senate bill, saying it’s something that really goes against everything he tried to do to cover people. Is that going to have an impact?
MR. RUCKER: I don’t know that it’s going to have an impact with the votes in the Senate, but it certainly has an impact with the politics surrounding all of this. I think he’s trying to help galvanize Democrats, who don’t really have a strong national party leader right now. Obama’s been very quiet through a lot of the Trump presidency so far. He’s not weighed in the way he weighed in on health care this week, and there’s a reason for that. It’s because this is his signature sort of bedrock legislative achievement, historic achievement from his presidency, and he wants to protect it.
MR. COSTA: Kelly, I know that the health care industry doesn’t seem to love this bill, but the business community seems to like it because it’s a tax cut.
MS. O’DONNELL: Well, part of how you can look at the two bills – meaning the Obama-era health care and what Republicans are talking about – is that Republicans are about trying to have entitlement reform, which you described. That is a core Republican view. They’re also trying to drive people to private insurance and not on state-covered insurance, so that’s also a core Republican view. And part of what the Democrats were trying to do was expand coverage so that it did create a much larger pool to try to drive down costs. We’ve seen that didn’t quite play out. So what Republicans need to do – and it’s going to be very difficult – in this is to try to support an insurance market that has taken hit after hit after hit. It’s not clear how they will bolster when we’ve seen different insurers leave marketplaces and so forth, but they’re trying to find a way to drive people toward private insurance and to incentivize that, and not to incentivize an expansion of government-backed insurance. Part of that is they’re looking down the corner and around when perhaps Democrats are back in power, and it could be not that far from single payer. So deep philosophical differences about how this would be playing out.
MR. COSTA: Sue, real quick, when you’re talking to lawmakers on Capitol Hill, Republicans, how do they weigh promising the base to repeal Obamacare with being maybe tagged as the party that went after Medicaid?
MS. DAVIS: That is a great question. I think, you know, there’s a raw political answer to this when we look at the midterm elections. And the fact of the matter is you could not have a better map in the Senate to put forward a politically risky bill like this. I mean, Republicans just aren’t that vulnerable in the Senate. They’re on –
MS. O’DONNELL: Only nine seats.
MS. DAVIS: And they’re – and they’re on the offense, they’re not on defense. So if you’re going to take a political risk, it’s a pretty good election cycle to do it. Mitch McConnell’s a pretty raw political strategist. I’m pretty sure he’s looked at the map the same way I have. But it’s absolutely a political risk. I mean, as a matter of health policy, which people feel very deeply about in this country, it’s probably the way that people most directly connect the federal government to their lives. But to Kelly’s point, this is also a bill that is, at its heart, a tax cut and a fundamental reimaging of an entitlement program, and those are two huge victories for conservatism.
MR. COSTA: I spoke to Senator Toomey of Pennsylvania, a Republican, a few hours ago. He said there’s still going to be a vote next week, but we’ll have to wait and see. A lot of looming issues for this health care bill.
But that wasn’t the only issue this week, because as health care consumes Washington, we’re getting some clues on how that and other issues are playing out across the country. I began the week in Georgia, covering Tuesday’s special election. Republicans won the $50 million political battle. The Democratic defeat stoked sharp discussions about how Democrats can win in red states. Republican Karen Handel beat first-time Democratic candidate Jon Ossoff to win Georgia’s 6th Congressional District. President Trump, who endorsed Handel, took a victory lap during a rally at Iowa the day after the election.
PRESIDENT TRUMP: (From video.) All we do is win, win, win. We won last night. (Cheers, applause.) They can’t believe it. They’re saying, what is going on?
We’ve 5-0 in special elections, 5-0. (Cheers, applause.) 5-0.
MR. COSTA: Phil, how – it was the fourth – actually, the fourth special election – excuse me, Phil, for one second – for Democrats this year. A small but vocal group of Democrats in that party are now suggesting the party needs new leadership at the top, and they’re taking aim at Minority Leader Nancy Pelosi, the California lawmaker, who remains defiant.
HOUSE MINORITY LEADER NANCY PELOSI (D-CA): (From video.) We’re paving a way for a new generation of leadership, and I – again, I respect any opinion that my members have. But my decision about how long I stay is not up to them.
MR. COSTA: President Trump couldn’t resist the chance to show his support for Pelosi. He tweeted: “I certainly hope the Democrats do not force Nancy P out. That would be very bad for the Republican Party – and please let Cryin’ Chuck” – that’s Senate Minority Leader Schumer – “stay!”
Phil, back to you. (Laughter.) What is the state of the Democratic Party right now? Are they rallying against Leader Pelosi, or is she pretty safe?
MR. RUCKER: You know, the one thing that could keep her in this position is she’s such a prodigious fundraiser. All of her members in the – in the Congress really rely on her to bring them money.
But the bigger problem for the Democratic Party right now is they need fresh faces, and they need a fresh message. They can’t run just as the resistance party. That’s what we learned in Georgia. That’s what we learned in all these other special elections. They need a vision for the future. They need a message. They need an agenda, some ideas, some policy ideas. Go out in the country. Try to figure out what a movement could look like. And they’re not there yet. They might get there by 2018, but they’ve got a lot of work to do as a party.
MR. COSTA: Sue, this is a party, though, of mostly baby boomers at the top.
MS. DAVIS: You know, the frustration at Nancy Pelosi I think is symblomatic of a bigger problem – symptomatic of a bigger problem is that, you know, it’s not just her; the top three leaders in the House Democratic Caucus combined have 90 years of service in the House of Representatives. There hasn’t been a lot of turnover at the top. Democrats at the top of the committees have – John Conyers of Michigan, Maxine Waters, I mean, luminaries of the party, people that are really popular within the party, but they’ve been around a long time. And there is a lot of frustrated ambition, particularly in the House Democratic Caucus.
Remember at the beginning of this Congress Pelosi was challenged for her leadership job. And a third of her colleagues voted against her staying on. And also remember that she had said if Hillary Clinton would’ve won, she was prepared to step down. So we’re certainly in the twilight years of Nancy Pelosi’s leadership. It’s unclear how much longer she’s going to serve. But I think there is a real concern that in these races where you have to win on the margins and tough seats, that she could be the margin, that she’s an anchor in swing suburban districts where they’re trying to appeal to a Republican’s constituency, and that Republican constituency does not like Nancy Pelosi.
MS. O’DONNELL: And if she weren’t from San Francisco – I mean, that just builds into the ad so nicely. When they want to have California values or Hollywood values, that makes her an easy target. She also has enormous name ID. So that makes her an easy foil in so many of the campaign ads.
But Phil, you’re right. Her ability to raise money – she’s the velvet hammer of the Democratic Party. She has a soft touch, and yet she really delivers. She has a way of keeping her caucus together.
And it’s tough at the top because it’s almost as if they were all waiting for the other one to retire, and it’s really tight at the top. But I think she really showed her resolve. No one’s going to tell her to leave until she’s ready to leave.
MR. COSTA: She’s a tough politician who grew up in Baltimore. Her father was mayor. She sees she could maybe be the next speaker of the House again. I don’t see her leaving anytime soon.
But Sarah, I’m really fascinated by how Democrats handle the policy front here as they look to 2018. I saw when I was down in Georgia, Ossoff was talking about health care, wasn’t really talking about Trump. Do you see Democrats fully seizing the health care issue?
MS. KLIFF: It’s interesting, and I think a lot of it will depend on kind of what happens over the next week. If the health care bill passes, you can bet that Democrats are going to be out there campaigning on it.
One of the interesting fissures to watch is if you do see a robust single payer or more national health care system movement kind of emerge out of this. And it seems possible to me at this point that Democrats might look at whatever the Republicans are doing and say, you know what, we tried to do the compromise route, we thought the Affordable Care Act was our attempt to do kind of a part public program with Medicaid, part private with the marketplaces; what we really wanted in out hearts, what President Obama will tell you, you know, if I could start from scratch, I would do single-payer.
And I think that’ll be very interesting to watch. I think, you know, to Phil’s point, that would certainly be a policy to run on. It would be a very different and kind of bold statement. I don’t know how exactly it’d play out. We’ve never seen the Democratic Party really embrace single-payer. But I think it’ll be interesting to watch in the wake of this Republican debate if they want to really, you know, refuel around this particular provision.
MR. COSTA: Well, as the Democrats think it all through and they try to figure it out, Phil, the president was in Iowa celebrating – defiant, as we saw in that clip – win, win, win. He’s had a string of success in special elections. But what does it tell us about – what’s revealing about the president’s confidence at this moment?
MR. RUCKER: Well, you’ve got to put the rally in context. It’s the first time he’s been out there on the political front as a campaign-style rally since Russia heated up, since firing Comey and the Comey testimony and the special counsel and all of that, and he’s had all of this energy stewing kind of pent up in the White House. And he just got out there and let it rip. He didn’t talk about Russia specifically, except for a reference to a witch hunt, but he was taking victory lap after victory lap – victory lap in that arena and loving it. And he loved the adoration of the crowd. He talked for more than an hour. That’s him in his element. He’s not a governing president. He’s a campaigning president. And I think the White House – I know the White House officials want to get him there on the road more and more.
MS. O’DONNELL: Is he tired of winning, Phil? Is he tired of winning yet? (Laughter.)
MR. RUCKER: Never tired of winning.
MR. COSTA: What’s this – what’s the debate within the Democratic Party about Russia, about whether to target that ahead of 2018 or not?
MS. DAVIS: I don’t think the Democrats really see Russia as the most potent campaign issue. I think regular voters have a very hard time connecting Russia to their lives. It’s amorphous. It’s ever-changing. It’s weird. It’s hard to understand. I think health care, if it – the bill moves forward, if it passes, if it becomes law, I think health care is a familiar ground that they’d much rather be litigating the 2018 midterms on, although I think part of the reason why the loss in Georgia was so sort of rattling to Democrats is I think that they saw this as a test case for a lot of those messages, and still coming up short has kept the party in a cycle of soul-searching. And a thing I think is important about Georgia and maybe fed his victory lap was it showed that Trump’s win was not a fluke.
MR. COSTA: What a week. Twenty-five million dollars in that Georgia race, the most expensive House race in history.
MS. O’DONNELL: Fifty (million dollars)
MR. COSTA: Fifty (million dollars). Twenty-five (million dollars) on the Democratic side, 50 (million dollars) overall. Kelly O., the expert. (Laughter.)
Thanks, everybody. Time to go. Our conversation continues online on the Washington Week Extra, where we’ll tell you why President Trump, admitting that he does not have tapes of his conversations with former FBI Director James Comey, has a few people scratching their head. You can find that Friday night after 10:00 p.m. at PBS.org/WashingtonWeek. I’m Robert Costa. Thanks for watching, and enjoy your weekend.