Health care hot potato

The American Health Care Act has resumed its zombie shuffle forward. No one — including House leadership — knows for sure whether the bill has the votes. Nor does anyone know what the modified bill will do, as Republicans didn’t unveil bill text until the 11th hour, and aren’t waiting for the Congressional Budget Office to assess the changes. “I don’t think we should pass bills that we haven’t read and don’t know what they cost,” Paul Ryan said in 2009. Today he will ask his members to do exactly that, and he will do so because he does not want them or the public to hear what his bill will cost, or who it will hurt. Ignorance may not be bliss, but the GOP seems to think it’s at least plausible deniability.

The dynamic that’s revived the AHCA is best described as health care hot potato. Few in the House affirmatively want the law to pass. But no one wants to be blamed for its failure. The House Freedom Caucus took the hit when the bill collapsed the first time, so they’ve been working feverishly to come up with a face-saving compromise. Eventually they did: The new bill lets states waive out of Obamacare’s insurance regulations. The Freedom Caucus pronounced itself satisfied, even though the effects of the compromise will likely be modest. They endorsed the bill. The hot potato was passed.

The problem is the waivers open the possibility that Obamacare’s popular protections for people with preexisting conditions will be rolled back in certain states. The expectation, at least as of now, is that a fresh CBO score would find coverage loss is even more severe in the new bill than the old one. This is anathema to the GOP’s more moderate Coverage Caucus, which, unlike the House Freedom Caucus, has objected to the AHCA on the grounds that it does not preserve enough of Obamacare’s coverage expansion and regulatory architecture. “We’ve talked about the protections for those with preexisting illness for [the] last number of years,” Rep. Fred Upton, a powerful Michigan Republican, said. “We’re not going to budge either.”

But as with the House Freedom Caucus before them, the Coverage Caucus may not like this bill, but they don’t want to be blamed for its defeat, either. Their answer appears to be twofold: appropriate $8 billion for high-risk pools, even though experts on both sides of the aisle say that’s not nearly enough to protect people with preexisting conditions, and move the bill before a CBO score reveals what exactly it is they’re voting for.

it’s time for some game theory. The Coverage Caucus could be trying to solve a number of problems. One problem is that the AHCA will throw tens of millions of people off health insurance and bring back the days when insurers could discriminate based on preexisting conditions, with catastrophic human and political costs. We know that’s not the problem they’re solving because their proposed modifications don’t solve that problem, and because they’re pushing a vote before CBO even looks at how much of that problem remains unsolved.

Another issue the Coverage Caucus could be trying to solve is they don’t want to be blamed for the AHCA’s second collapse. This objective fits their actions much better. Conventional wisdom among House moderates is that the Senate will rip this bill to shreds, and so the best strategy is to strike a face-saving compromise and pass it out of the House so Senate Republicans can do the work of either killing it or crafting something that’s not a disaster. Pass the health care hot potato to the Senate, in other words.

The logic of playing health care hot potato is compelling, and you can even see how it could lead to the bill’s eventual passage. It could be that Senate Republicans also decide they don’t want to be blamed for the bill’s failure, even as they don’t much want it to succeed. If GOP leadership invents a face-saving way to vote “yes,” like promising that Health and Human Services Secretary Tom Price will use some unspecified regulatory authority to make sure nothing bad ever happens to anyone, perhaps the Senate will pass the hot potato, too.

The problem with health care hot potato is that if no one stops the game, the hot potato eventually gets passed to the country — and millions get burned. The AHCA remains comically unpopular, and that’s before it has canceled the subsidies tens of millions of people rely on to purchase insurance. The GOP is creating a collective action problem where every individual legislator is rationally refusing to be the cause of the bill’s failure, but that could mean the entire party ends up responsible for its catastrophic success.