Trump healthcare bill dangles by a thread

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Media captionWill Trump seal the healthcare deal?

It's time for Donald Trump, the man who bills himself as the consummate dealmaker, to flex his negotiating muscle - or else.

The American Health Care Act, which rolls back portions of the Obamacare medical insurance reforms, is scheduled for a vote in the House of Representatives on Friday. The bill was initially scheduled to go before the House on Thursday, but was delayed amid concerns it would not garner enough votes.

Even with the delay, it remains far from certain that there are the 215 votes necessary for passage. Vote counts are like party RSVPs. You never know how many people will show up until well after the food is set out and the wine has been uncorked.

What is certain, however, is that the stakes in this legislative showdown couldn't be higher as the White House has insisted the House press ahead with a vote. Republicans have spent the past seven years railing against Barack Obama's healthcare reforms, and if they fail to take the first legislative step toward repeal on Friday it will be a major setback for both the Republican congressional leadership and the president, who has put his reputation as a skilled negotiator on the line.

In Washington, power begets power. Successfully wielding it makes you stronger, while failure reveals weakness and engenders future failure.

A loss on Friday would force Congress to restart the entire healthcare repeal process - or, as White House officials threatened on Thursday night, abandon the efforts entirely. A return to the drawing board would delay work on the rest of their legislative agenda, including tax reform - a heavy political lift on its own - and an infrastructure bill. A full abandonment would embolden Trump critics on the left and the right in future legislative battles.

The Republicans had set out an ambitious schedule for passage of the healthcare bill, with a Senate vote expected as early as next week. Any delay will probably push a final bill, if it can be achieved, well past the Easter congressional recess.


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Concerns about complications resulting from the bill's failure are likely not among the top concerns of rank-and-file Republicans in the House, who find themselves in a tricky position. Several conservative groups are putting this bill in an unwelcome spotlight, taking note of how lawmakers vote for their end-of-year legislative scorecards.

The anti-abortion Right to Life will give positive marks for a yes vote, as will the evangelical Faith and Freedom Coalition. Grassroots conservative groups Americans for Prosperity and the Heritage Action Fund, on the other hand, have said they will make no a "key vote".

In other words, House Republicans are going to hurt themselves one way or another. They face the unpleasant task of determining the course of least pain.

Mr Ryan has been doing what he can to sweeten the pot for disgruntled legislators - although that has often resulted in the bill being stretched in different directions, like so much legislative taffy. How far can the speaker pull it before it breaks?

Conservatives have been offered a rollback of federal mandates for "essential coverage" all health insurance plans must provide, the ability to add work requirements for the able-bodied poor on Medicaid and the ability for states to receive Medicaid money in block grants to do with as they please.

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Image caption A 64-year-old lung cancer survivor in West Virginia

Moderates were given the promise of $75bn to help older low-income individuals pay insurance premiums and more funds to help states pay for coverage requirements they may wish to impose in place of the repealed federal guidelines.

Despite all the drama, as far as bars for presidential success go, the House vote is a relatively low one. The speaker and his leadership team wield extraordinary power to shape the rules of debate in their favour and the amount of pressure they can bring to bear on individual members is great.

If indeed the number of probable Republican "no" votes that need to be flipped can be counted on one's fingers, Mr Trump and Mr Ryan have a reasonable shot at pushing the bill across the finish line, although there may be some tense moments.

There's also the possibility that if, as the hour of the vote approaches, its prospects appear to dim, uneasy House members will rush to the exits.

While failure here would be a disaster for the White House, exposing the president as a paper tiger and the speaker as being at the mercy of his rebellious caucus, a victory only clears the way for tougher challenges in the days to come.

The efforts to appease hard-line conservatives in the House will probably rankle Republican moderates in the Senate, some of whom - such as Susan Collins of Maine and Lisa Murkowski of Alaska - are already on the record saying the original Medicaid cuts were too steep.

A handful of hard-line conservatives have also voiced their opposition.

With only a two-vote majority in that chamber, three Republican defections will sink the bill (and that number drops to two if Georgia Senator Johnny Isakson, a reliable yes vote, can't quickly recover from back surgery).

Senate passage, which looks tenuous at best, would then probably be followed by an attempt to reconcile major differences in the House and Senate bills, and then another round of votes in both chambers to approve the resulting compromises.

After that, congressional leadership promises another piece of legislation with more substantive changes to the US healthcare system, such as paring back mandatory insurance coverage guidelines and allowing individuals to purchase from out-of-state insurance providers. Those measure will require 60 votes in the Senate to break a near-certain Democratic filibuster.

In other words, it won't get any easier from here.

As the president might say, who knew legislating could be so complicated?

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