Trump's All-the-Above Sales Strategy on Health Plan

Trump's All-the-Above Sales Strategy on Health Plan
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A week into President Trump’s pitch to replace Obamacare with new law, the White House used gentle lobbying mixed with not-so-subtle political warnings to encourage conservatives to stand behind a measure criticized from the Right and the Left.

There was a reason Vice President Pence flew to Louisville, Ky., Saturday morning to push for the embattled House bill, which Kentucky GOP Sen. Rand Paul dismissed during multiple TV and radio interviews as “dead on arrival” in the Senate. 

The Pence visit was intended to underscore to Paul and others that Kentucky voters dislike Obamacare, defeated the state’s former Democratic governor, and backed Trump in no small measure because of the political potency of health coverage issues, White House Legislative Affairs Director Marc Short said during a brief interview on Thursday.

Trump phoned the senator the same evening, assuring Paul that “he’s open to negotiation” on provisions of the House bill, Paul said Friday during a Breitbart News Daily radio interview. But Paul insisted he still wanted a “clean” repeal of the Affordable Care Act first, followed by a separate, market-based replacement for President Obama’s signature legislative invention. 

As of Friday, Trump had been treating GOP holdouts with velvet gloves, using, for example, his Twitter account to call Paul “my friend,” and hosting a private White House dinner for Sen. Ted Cruz -- another leading critic of the House bill -- and his family.

But if the White House had hoped Kentucky’s GOP governor might link up with Pence and help pressure Paul to side with Trump and House Speaker Paul Ryan in the interests of red state politics, the plan wobbled badly. Gov. Matt Bevin, who won election while assailing Obamacare, sounded a cautious note when he told reporters on Friday that he’s no fan of the House GOP health plan.

“Sen. Paul … is not impressed with what has currently been offered. Truth be told, I’m not either. So I’m with him,” Bevin said.

The president touts the House measure -- which would alter existing law, enacted in 2010, while retaining some key provisions -- as a “rescue” for Obamacare “that follows the guidelines that I laid out” last month in his speech to Congress. But for every offer to GOP lawmakers to embrace some of their ideas as part of the legislative process, Trump is also encouraging defections from renegade conservatives as well as from GOP moderates who worry about what follows repeal.

The president’s maiden legislative lobbying adventure this week was a hybrid of behind-the-scenes lobbying, cheerleading, one-on-one hand-holding, and privately delivered warnings about bleak political consequences should Republicans fail to deliver on their campaign promise to erase Obamacare. 

“I got elected to a certain extent -- I would say a pretty good little chunk -- based on the fact [of] repeal and replace Obamacare. And many of you people are in the same boat,” Trump told House GOP lawmakers gathered at the White House this week. “Very important. So let’s get it done,” he added. 

The president is betting that GOP lawmakers are more afraid of not repealing Obamacare before facing voters in 2018 than reckoning with political blowback if they end up withdrawing health coverage from their constituents who may have it now. One complication for Trump is the fact Americans who have benefited from the Affordable Care Act are also a big part of his political base. Obamacare may be unpopular, but if its replacement takes coverage away from millions of voters who now have something, Trump’s name is branded on the result.

White House aides and a few Cabinet members, plus the vice president, invested hours this week participating in 105 radio and TV interviews with stations sprinkled throughout states Trump won, and where the president’s team believes GOP lawmakers need White House support as they weigh a House vote on a measure that could later be sidelined in the Senate.

Pence, Health and Human Services Secretary Tom Price, Office of Management and Budget Director Mick Mulvaney, and senior Trump advisers explained to Americans that replacing Obamacare involves three complex stages: passage of the House bill in the two chambers using a budget process that requires just 51 votes in the Senate; a separate HHS phase of Obamacare changes built on regulatory underpinnings of the existing law and changes that may be enacted based on the House measure; and a third phase of health care changes that could appease GOP conservatives who are balking now. But to get changes such as risk pools for small employers and health insurance sales across state lines, Congress would need to find bipartisan support in the Senate.

Trump did not appeal directly to the American people about his legislative push beyond his taped radio address this week. He is scheduled to headline a political rally in Nashville, Tenn., on Wednesday, where he is expected to endorse the House measure as the best chance to repeal and rescue the ACA from what he has repeatedly predicted as certain collapse.

The president’s White House surrogates explaining the House plan in radio and TV interviews included Counselor Kellyanne Conway, Domestic Policy Council Director Andrew Bremberg, Press Secretary Sean Spicer, and Principal Deputy Press Secretary Sarah Huckabee Sanders.

But combatting their advocacy were House and Senate Republicans, who watched the proposed measure move through two committees with a cacophony of criticism from within their party. The unified Democratic opposition was assumed, and was almost an asterisk in the broader debate.

“There’s nothing that Democrats could do that would be more impactful than what the Republicans are doing to each other,” Emily Tisch Sussman, campaign director for the progressive Center for American Progress, told RCP.

Sussman said GOP alarm over provisions of the House plan has compelled some conservative lobbyists to reach out to Democrats to see if they can join forces to try to scuttle the House plan. Replacing Obamacare could inspire an unexpected bipartisan alliance: Democrats want to block the House plan in order to keep the ACA intact or fix it; Republicans want to block the House plan, even as they seek to repeal the ACA.

“The simplest and most direct way and the thing that unites Republicans is clean repeal. After all, every single one of us voted for it just 15 months ago,” Rep. Jim Jordan, R-Ohio, co-founder of the conservative House Freedom Caucus, said Friday. “So clean repeal, then we can have the debate on what should be in a replacement.”

 Conservatives oppose the ACA’s Medicaid expansion to the states and seek to sunset the more generous federal support for low-income health coverage earlier than proposed in the House replacement plan.

On Friday, Spicer said Trump is open to that idea, even as the president embraced the bill as passed by House committees. But the president is more staunchly wedded to another deal-breaker among GOP conservatives: enactment of refundable tax credits to help families afford private health coverage to replace the tax subsidies included in existing law. GOP conservatives assail the tax credits as an objectionable new federal entitlement. Spicer said Trump “absolutely” supports the proposed credits.

White House lobbyist Short, who previously worked with Pence when the vice president served in the House, said threats by conservative groups to try to block the House plan by investing in opposition campaigns and advertising appeared to be small.

But opponents of the White House-backed measure are unlikely to get more publicly assertive and organized unless and until the current plan clears the House and makes its way to the Senate, analysts predicted in interviews with RCP.

A Democratic coalition that helped enact the ACA seven years ago has reunited as “Protect Our Care,” with additional support from grassroots voters who spontaneously turned out this month at town hall events to tell lawmakers to fix, rather than repeal, Obamacare.

That coalition is looking at the GOP upheaval as educational to Americans of all political stripes about the innards of the House plan. “The Republicans are doing a lot of the messaging themselves,” Sussman noted.

Democratic groups and progressives who want to preserve the goals of the ACA believe they can keep that educational component in the news and perhaps defeat the House plan in the Senate with delaying tactics that could aggravate Trump’s impatience and his ambitions for a swift legislative victory before Easter -- before turning to comprehensive tax reform on Republicans’ checklist.

Congressional Republicans seized some control of the legislative calendar in 2009 and 2010 before Obama signed health reform into law. His futile search for Republican votes, then his arm-twisting to get enough Senate Democrats to back the Patient Protection and Affordable Care Act resulted in an 18-month marathon that sapped his legislative heft and resulted in a complex public-private insurance system that expanded coverage to an estimated 20 million people while also hurting Democrats politically through four election cycles.

“I think that is how we defeat it,” Sussman said of Democrats’ strategy to block the GOP replacement plan. “The dragging it out is how we defeat it.”

This week, Republicans helped.

Alexis Simendinger covers the White House for RealClearPolitics. She can be reached at asimendinger@realclearpolitics.com.  Follow her on Twitter @ASimendinger.

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