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Trumpcare’s long odds in the Senate, explained by a Republican senator

Sen. Bill Cassidy, R-La.
Bill Clark | CQ Roll Call | Getty Images
Sen. Bill Cassidy, R-La.

Congressional Republicans and the White House are making another huge push this week to move their Obamacare repeal bill, the American Health Care Act, through the House.

And if they succeed, Sen. Bill Cassidy (R-LA) explains, their reward will be to watch senators rip up the bill and start over.

"I expect the Senate to do something different. I don't expect we'll vote on the House bill as it is," Cassidy said in an interview last week. "I expect we will put forward our alternative."

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Cassidy and I chatted onstage last week during the Vox Conversations unconference. He did not speak especially favorably about the House plan. Instead, he pointed out the ways the AHCA falls short of President Trump's campaign promises to cover everybody and lower premiums.

What follows is an excerpt from our conversation, where we discuss how Cassidy expects the health care debate to proceed in the Senate and why he has concerns about the House bill. If you want to read more about Cassidy's own proposal, the Patient Freedom Act, you can read a separate interview we did about it here. A video of the entire interview is also available.

Sarah Kliff

The House Freedom Caucus just endorsed the American Health Care Act. Where do you see that going in the Senate, and where do you stand on the American Health Care Act?

Bill Cassidy

The Senate will obviously put forward its own bill. That's appropriate. I can't say it's going to be completely [well-]received. When candidate Trump ran, he had several guarantees. He wanted to lower costs. There are two ways to perceive that. You can either perceive [a lower cost] as getting a better [Congressional Budget Office] score, but most perceive it as lower premiums. I will judge it [on] does it fulfill candidate Trump's pledge of lower premiums? He also said he wanted everyone to have coverage, to care for those with preexisting conditions without mandates. My judgment is based on candidate Trump.

I think Trump's coalition of voters, they expect President Trump to live up to candidate Trump's pledge.

Sarah Kliff

What is your goal in health care reform, and does it align with the goals of your colleagues in Congress?

Bill Cassidy

My goal is to complete candidate Trump's pledge. I'm a physician, worked for 25 or 30 years in a hospital for the uninsured. As I look back at the patients I saw, I could imagine many voting for Trump and many voting for Clinton. This isn't like a Democrat or Republican issue. It's an American issue.

I get people emailing me all the time horror stories about their premiums. Does this plan lower premiums? CBO previously said the previous iteration raised them by 20 percent relative to Obamacare over the next two or three years. If that is the case, that will be a $50,000 a year premium. This is nuts.

Sarah Kliff

It sounds like from everything you're saying that you're not a huge fan of the American Health Care Act. It's not living up to the premium goal, the coverage goal. Is that a bill you could see yourself supporting?

Bill Cassidy

I expect the Senate to do something different. I don't expect we'll vote on the House bill as it is. I expect we will put forward our alternative.

Sarah Kliff

We've watched the Republican Party campaign on repeal and replace for about seven years. Now that we've gotten to the point where you all are in control of the White House and Congress, it seems fair to say it's been a challenge to move forward.

What is hard about getting the party together on Obamacare repeal and replace? What are the big roadblocks?

Bill Cassidy

It's complicated.

Sarah Kliff

I have heard that before!

Bill Cassidy

I guess the roadblocks are you have to socialize everybody to certain concepts. One example: The American Health Care Act had a provision that if you weren't working, you couldn't get a credit. There is a gentleman at Heritage Foundation who said it won't work. EMTALA, the Emergency Medical Treatment and Labor Act, means that someone can walk into the emergency room and get treated. Federal law requires that.

If you get in a wreck with multiple trauma and you're in the hospital for six months, society eats that cost. I think people have to become emotionally aware and intellectually aware of the fact that Congress, when it passed EMTALA, made that a right.

I see as people become more aware of these issues [that] we're moving more to an agreement on our approach.

Sarah Kliff

Your bill seems like a bill written for compromise. It lets states that like Obamacare keep Obamacare, and lets states that don't like it opt out. Right now it seems like there isn't much appetite for compromise. Democrats want to keep Obamacare in all the states. The Freedom Caucus wants to get rid of it entirely.

What reaction do you get from Democratic senators when you talk to them about this proposal?

Bill Cassidy

As a conservative, I think we should turn things over to the states if we can reasonably do so. To think that California has a plan that will do just as well there as it will for Iowa and for Alaska is crazy. Those states are very different.

Why not allow the state to figure things out? We've seen Maine and Alaska doing the hidden reinsurance pool, very innovative. So we see that states come up with these solutions that actually work.

Democrats cannot accept right now an erosion of Obamacare politically. I think their far left is so providing energy, and driving what they're doing, that even a good-faith effort like we are putting forward cannot yet be accepted. I find that incredibly regrettable, because if Tennessee is about to have a death spiral to their individual market, why in the heck would a blue-state senator insist that they go into a death spiral? Why not allow Tennesseans to work out a solution for Tennessee?

Sarah Kliff

What about your colleagues to your right? How do they feel about your plan letting Obamacare stand in some states?

Bill Cassidy

Some may think they are to the right of me, but if they're trying to replace the tyranny of Obamacare with the tyranny of the Republican plan that you have to do no matter what, I don't consider that a conservative solution. That's what conservatives blame the Democrats for: the tyranny of the elite telling you how to run your state. I don't considerate that the conservative solution. I consider that the tyrannical solution.