House Speaker Paul Ryan, R-Wis., is laying it all on the line for repealing and replacing Obamacare.
Ryan acknowledged to conservative radio host Hugh Hewitt that if Congress fails to pass the American Health Care Act, it will be a major “momentum killer” for the rest of the Republican agenda.
Even though the Obamacare replacement has been nicknamed “Trumpcare” in honor of the new president, the plan is substantially Ryan’s, in conjunction with allies House Ways and Means Committee Chairman Kevin Brady, R-Texas, and House Energy and Commerce Committee Chairman Greg Walden, R-Ore.
Conservative groups opposed to the bill have in fact re-christened it “Ryancare,” a reflection of the fact that Tea Party groups are more willing to attack the orthodox movement policy wonk’s conservative credentials than the heterodox Republican president’s.
The speaker took off his jacket and rolled up his shirtsleeves last week to go through a 20-minute PowerPoint presentation defending the plan the House Freedom Caucus and a handful of conservative senators have instead dubbed “Obamacare lite.”
“This is the closest we will ever get to repealing and replacing Obamacare,” Ryan said. He tried to demonstrate the continuity between the House Republican plan and decades of conservative healthcare policy proposals, dating back to Ronald Reagan’s ideas for revamping Medicaid when he was governor of California.
While Rep. Mark Sanford, R-S.C., described the bill as an “opening bid,” Ryan said, “It really comes down to a binary choice.” “This is the choice we face,” the speaker argued. “Are we going to stay with Obamacare… or are we going to do what we said we would do?”
“‘Binary choice’ fallacy is a tool partisans on both sides use to quash policy debate and avoid difficult job of persuading and legislating,” protested Rep. Justin Amash, R-Mich., via Twitter shortly afterward.
Amash and Sanford are among the 30 House Republicans targeted by a leadership-backed ad campaign in support of the American Health Care Act. The spot tellingly features President Trump rather than Ryan.
Ryan has guaranteed the bill will have majority support by the time it reaches the House floor. Republican Capitol Hill sources are split on how close Ryan is to reaching this goal. “No way this passes as written,” said one GOP congressional aide. Another working for a member skeptical of the legislation said stopping or substantially changing it would be an “uphill battle.”
In the Senate, there are even fewer votes to spare. Sens. Rand Paul, R-Ky., Mike Lee, R-Utah, and Ted Cruz, R-Texas, have all been critical from the right. But Sens. Rob Portman, R-Ohio, Shelley Moore Capito, R-W.Va., Cory Gardner, R-Colo., and Lisa Murkowski, R-Alaska, have all warned against rolling back the Medicaid expansion.
Ryan is severely hamstrung by this vote math and the process he must use to advance any legislation through the Senate. The American Health Care Act is written to repeal Obamacare through reconciliation, a mechanism that will allow the bill to avoid a Democratic filibuster and pass with a simple Senate majority.
In order to use reconciliation, everything in the bill must be germane to the budget. For this reason, Obamacare taxes and spending can be repealed, but a lot of the regulatory changes free-market healthcare reformers want to see cannot be a part of the initial legislation.
Additionally, Republicans control only 52 seats in the Senate. While Ryan can lose as many as 21 Republicans in the House, in the Senate there can be no more than two GOP defections. Ryan and Senate Majority Leader Mitch McConnell, R-Ky., need the bill to have overwhelming Republican support.
By contrast, Democrats had nearly three-fifths majorities in both houses of Congress when they passed Obamacare in the first place. At one point in the process, they even had a filibuster-proof 60-vote majority in the Senate.
Perhaps that’s why “consensus” is a word Ryan favors when selling the bill to conservative audiences.
“This reflects a Republican consensus, and that’s the point. It’s a consensus bill,” Ryan told Hewitt. “We’re going through the growing pains of being an opposition party with Barack Obama to actually being a governing party with a Republican president, Donald Trump. And that means we have to reach consensus on Republican priorities and principles.”
So far, President Trump has been supportive of Ryan. He has tried to rally Republicans behind the bill, cajoling publicly on Twitter and meeting with wavering members privately. Trump has told leaders he is willing to back primary challenges against Republicans who vote against it. Vice President Pence promoted the bill in Kentucky on Saturday.
Conservatives who have met with Trump or Pence about the legislation say they believe the administration is more willing to negotiate on the specifics of the bill than Ryan and other congressional leaders — the president especially. But they also came away believing Trump was committed to passing something and opposed to inaction on healthcare.
That’s why Ryan remains a pivotal figure. He faces a tall order in getting a bill passed with fractured Republican majorities over the opposition of the American Medical Association, AARP and the American Hospital Association. Insurers are divided.
The Wisconsin Republican honed his reputation as a dedicated advocate of entitlement reform and conservative policy innovation, but as he has risen up the leadership ranks criticism from his right has grown.
“He’ll be called a RINO no matter what he does,” conceded a Republican congressional aide.
Nevertheless, Ryan forges ahead with the healthcare bill, which has now cleared two House committees with unanimous Republican support.
This post originally appeared on Washington Examiner