Backing Ryan's New "Crueler" Health Plan, Trump Threatens Reluctant Lawmakers

President Donald Trump appeared on Capitol Hill early Tuesday to strong-arm lawmakers into voting for the updated version of the GOP's American Healthcare Act (AHCA), which overnight was made "even crueler to the poor and working class" in a bid to win over the most conservative faction of House Republicans.

Ahead of Thursday's House vote, Republican leadership late Monday unveiled a "manager's amendment" to the plan to repeal and replace the Affordable Care Act (ACA), or Obamacare, which includes gifts to the Republican Study Committee as well as anti-choice conservatives.

Inserted to provide some "red-meat for the right," according to Politico, which first reported on the plan, is a provision that allows states to demand that recipients of Medicaid work for their aid as well as gives states the flexibility to take their Medicaid funding as a lump sum block grant rather than a per-person check.

Further, the amendment "speeds up the repeal of about a dozen Obamacare taxes a year earlier than originally planned, a win for conservatives who want to eliminate the Affordable Care Act as quickly as possible," Politico reported, adding that the provision would further "delay implementation of the Cadillac tax again, this time from 2025 to 2026."

The bill also "deletes a provision that would have allowed consumers to move leftover tax credit money into a Health Savings Account," a change sought by anti-choice groups which claimed that the rule "inadvertently allow[ed] for taxpayer funding of abortion," the outlet noted.

Lastly, in an explicit gift to upstate New York Republicans, the amendment shifts Medicaid costs from New York's counties to its state government, saving county governments outside of New York City $2.3 billion a year, according to the New York Times.

Despite the myriad problems presented by the Republican plan, including the Congressional Budget Office (CBO) estimate that it would eliminate coverage for 24 million people by 2026, observers argue that the changes only seem to address the AHCA's political roadblocks.

David Himmelstein and Steffie Woolhandler, co-founders Physicians for National Health Program and members of the progressive "Shadow Cabinet," reacted to the changes on Twitter:

"These aren't changes that address the core problems the GOP health care bill will create for voters, insurers, or states; instead, it's legislation that tries to solve some of the problems the bill creates for conservative legislators," wrote Vox's Ezra Klein on Monday. "Both the process and the substance of the American Health Care Act have revealed a political party that has lost sight of the fact that the true test of legislation isn't whether it passes, but whether it works."

The only provision within the manager's amendment that attempts to address the cost of the plan for working Americans (and the GOP lawmakers who have to answer to them) is a measure that "would set aside funding--about $85 billion, according to Republican sources--for tax credits to help Americans between 50 and 64, who would see their premiums skyrocket under the current repeal plan," Politico wrote. "The amendment would not set up the tax credits but would instruct the Senate to do so, forcing House Republicans to take a vote on something the upper chamber would do later."

According to the CBO analysis, a 64-year-old making $26,500 would see their premium increase from $1,700 under the ACA to $14,600 under the Republican plan.

In a statement Monday, House Speaker Paul Ryan (R-Wis.) spun the changes as boon to tax payer's and older Americans."With this amendment, we accelerate tax relief, give states additional options to spend health care dollars how they choose, strengthen what were already substantial pro-life protections, and ensure there are necessary resources to help older Americans and the disabled," Ryan said.

Economist Paul Krugman had a different take:

As for whether the changes succeeded in winning over conservative holdouts, The Hill reported on Tuesday:

The Hill's Whip List shows that 17 House Republicans currently plan to vote no on the healthcare legislation, suggesting the final vote tally will be a nail-biter. Ryan and his team can only afford 21 GOP defections if all Democrats vote no, as they are expected to do.

GOP leadership aides declined to share their internal whip count but said they are picking up votes daily and "feel very good about where we are and how our conversations are going."

For his part, Trump reportedly threatened House Republicans on Tuesday, saying essentially, "If you don't pass the bill there could be political costs," Rep. Walter Jones (R-N.C.) told the Associated Press.

House Freedom Caucus chairman Mark Meadows announced that his group will no longer formally oppose the AHCA, but many note that the updates only increase the likelihood that the AHCA will be "dead on arrival," as Klein put it, when it reaches the Senate.

And in the outside possibility that it becomes law, the outcome could be demonstrably worse for Trump, Republican lawmakers, and American voters.

As Klein wrote:

Republicans have been promising the literal opposite of the bill they are trying to pass. Trump swore he'd oppose Medicaid cuts--but this law has more than $800 billion of them. He said everyone would be covered--but the CBO estimates this bill will push up the ranks of the uninsured by 24 million people. Republicans everywhere said they would replace Obamacare with a plan that ensured more competition, lower premiums and deductibles, and an end to skyrocketing annual increases--but this bill will have the opposite effect for most of those affected.

So what happens when voters realize their new tax credit doesn't cover anything close to the insurance they had? What happens when they find themselves with fewer choices, paying much higher premiums after their smaller subsidies, and being told by insurers that costs are doubling because Republicans changed how much more the old could be charged than the young?

If recent town hall protests are any indication, Klein predicts: "Voters will notice all this."