'This Week' Transcript 5-7-2017: Speaker Paul Ryan and Sen. Susan Collins

PHOTO: Speaker of the House of Representatives Paul Ryan arrives at 11 Downing street in London, April 5, 2017. Senator Susan Collins at the Grammys on the Hill Awards on April 5, 2017.PlayEPA\Getty Images
WATCH Speaker Ryan calls House health care bill 'rescue mission,' says GOP is 'keeping our word'

THIS IS A RUSH TRANSCRIPT FOR 'THIS WEEK' on May 7, 2017 and it will be updated.

(BEGIN VIDEO CLIP)

ANNOUNCER: Starting right now on THIS WEEK with George Stephanopoulos.

DONALD TRUMP, PRESIDENT OF THE UNITED STATES: We don't have to talk about this unbelievable victory. Wasn't it unbelievable?

ANNOUNCER: High stakes over health care. Donald Trump declaring victory.

TRUMP: How am I doing? Am I doing OK? I'm president. Hey, I'm president. Can you believe it?

ANNOUNCER: As the GOP's bill passes with one vote to spare.

UNIDENTIFIED MALE: The bill is passed, and without objection the motion to reconsider is laid upon the table.

ANNOUNCER: Now, Republicans under fire for backing the bill.

UNIDENTIFIED FEMALE: These are human beings!

UNIDENTIFIED FEMALE: Does every aspect of this bill apply to members of Congress?

CROWD: No.

ANNOUNCER: What does it mean for your health care? Will this bill cost the GOP in the next election? We ask House Speaker Paul Ryan in our exclusive live interview, his first since the big vote.

And as the battle over the bill continues --

CROWD (chanting): Shame, shame, shame.

ANNOUNCER: -- will it stall in the Senate? We talked to one senator who could block the bill.

From ABC News, it's THIS WEEK. Here now, chief anchor George Stephanopoulos.

(END VIDEOTAPE)

GEORGE STEPHANOPOULOS, ABC HOST: Good morning. Back in March, the GOP effort to repeal Obamacare seemed to end with more whimper than bang. After seven years of debate, dozens of symbolic vote, Republicans couldn't rally behind a bill that might actually become law. Obamacare, for all its problems, appeared too popular to kill, the benefits too meaningful to too many.

It's kind of an iron law of politics. Once the government provides a benefit, it's almost impossible to take it back. We've seen it with Social Security. We've seen it with Medicare. Now that law is being put to its biggest test in generations.

Cut to the Rose Garden this week. President Trump and Speaker Ryan savoring a victory, backed by dozens of cheering House members who cobbled together a repeal compromise that passed with a single vote to spare.

(BEGIN VIDEO CLIP)

TRUMP: This is a great plan. I actually think it will get even better. And this is -- make no mistake -- this is a repeal and a replace of Obamacare. Make no mistake about it. Make no mistake.

(END VIDEO CLIP)

STEPHANOPOULOS: Here's the surprising thing. Back in the house, Democrats appear just as pleased. Leader Nancy Pelosi closed the debate by warning Republicans they were making the mistake of their careers.

(BEGIN VIDEO CLIP)

REP. NANCY PELOSI (D-CA), MINORITY LEADER: You have every provision of this bill tattooed on your forehead. You will h glow in the dark on this one. You will glow in the dark.

(END VIDEO CLIP)

STEPHANOPOULOS: And as the final vote were counted, her troops broke out in song.

(VIDEO CLIP PLAYING)

STEPHANOPOULOS: All of this sparked a rare bipartisan scolding from "The New York Post" -- Children, they're all children.

Point taken. The stakes in the debate too high for silly games, but both sides may also be right. The GOP needed a win now, needed to show their base they could deliver on a big promise. But if history holds, they could pay a big price later. Democrats lost control of Congress in 2010 after passing Obamacare in 2009.

And in town meetings this weekend, members of Congress are facing tough questions and raw feelings.

(BEGIN VIDEO CLIP)

UNIDENTIFIED FEMALE: You are mandating people on Medicaid accept dying. You are making Americans --

REP. RAUL LABRADOR (R), IDAHO: No one wants anybody to die. But you know, that line is so indefensible. Nobody dies because they don't have access to health care.

(SHOUTING)

(END VIDEO CLIP)

STEPHANOPOULOS: That emotion is fueled by a simple fact. What happens to health care matters to everyone. Everyone has a stake. Everyone has a story. Everyone wants the health care they need at a price they can afford. Rarely does official Washington touch so many lives so directly and so deeply.

This morning, three big questions on the table. How will repeal legislation passed by the House affect all of us and America's health care system overall? Can legislation that looks anything like that bill actually pass the Senate? Leaders there already saying they're going to start from scratch. And what will be the political fallout? When this debate ends, which party will own health care, at what cost?

And we begin with a personal impact from one of America's premiere health officials, Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston, a professor at Harvard, a staff writer at "The New Yorker", and an author of 40 "New York Times" best-sellers, most recently "Being Mortal: Medicine and What Matters in the End".

Dr. Gawande, thanks for joining us this morning. So speak from the perspective of a doctor first. What's your biggest concern with this bill?

DR. ATUL GAWANDE, SURGEON, BRIGHAM AND WOMEN'S HOSPITAL: I read the bill and there are three big concerns. One is the weakening for protections of people are pre-existing conditions. Another is the major cuts in the number of people who are on Medicaid coverage. And then the third is the increased cost for people who buy insurance on their own, especially if they're over 50.

STEPHANOPOULOS: So let's take those one at a time, starting with the pre-existing conditions. Got so much attention this week particularly after that monologue from Jimmy Kimmel. Want to show a bit of that.

(BEGIN VIDEO CLIP)

JIMMY KIMMEL, HOST, " JIMMY KIMMEL LIVE!": If your baby is going to die and it doesn't have to, it shouldn't matter how much money you make. I think that's something whether you're a Republican or Democrat or something else, we all agree on that, right? I mean, we do.

(CHEERS AND APPLAUSE)

(END VIDEO CLIP)

STEPHANOPOULOS: Now, we know what happened with the House bill. They were basically giving the states the option to waive the requirements so that people could be charged higher premiums who had preexisting conditions. They also added some money to pay for that. The president looks at all that and says the coverage for preexisting conditions will be the same now as it was under Obamacare. Your response?

GAWANDE: Well, it's hard for me to watch that Jimmy Kimmel clip, because my own son, who is 20s, and he has almost the same heart condition. When he turns 27, he goes out on the market. And most of the jobs he has had are freelance jobs with no benefits. He's like 1 in 4 Americans that are, with histories of cancers, to diabetes, to heart conditions. And my worry as father, as a cancer surgeon, is that when we say we're going to put people into high-risk pools, we have seen what that is. High-risk pools are separate insurance plans for people with preexisting conditions. And they've historically had very low coverage, waiting lists, poorer coverage, and high costs.

It's -- it's chilling to imagine my telling my son those are where he would end up going or my own patients.

STEPHANOPOULOS: And then the Medicaid savings, about $880 billion in savings according to the Congressional Budget Office.

GAWANDE: Right, it cuts the 70 million people on Medicaid by about a quarter. And for the rest of the people, there's a cap, whether it's the elderly in nursing homes, people who are working poor, the cap would mean that the coverage becomes limited.

STEPHANOPUOLOS: And then, finally, because of the way they affect the subsidies, some older and sicker Americans will be paying more.

GAWANDE: Yes. People who are over 50 can be charged under this new bill up to five times more than younger people.

STEPHANOPOULOS: But how about if you take the flip side, right, it's very clear right now for a lot of younger and healthier Americans, their premiums have gone up under Obamacare. We have also seen insurance companies facing losses. A lot of insurance companies facing losses in states most recently like Virginia and Iowa, big insurance companies pulling out of those states. That fuels the president's argument, the speaker's argument that Obamacare is collapsing.

GAWANDE: So, of course what's happening is that there's uncertainty in the market about will there be subsidies, will there be mandates? And so the insurers don't know how to price and are pulling out.

Here's the thing to understand is that this is not -- this is a bill that makes each measure of health and health care worse, rather than better than under Obamacare. It's not a proposal that anybody would put forward as a credible or sane proposal for solving the problems in Obamacare.

STEPHANOPOULOS; Why not?

GAWANDE: Well, the core reasons are, number one, it doesn't have the -- the subsidies. So, by cutting the subsidies substantially, we're taking $1 trillion away from support for people's health care in the bottom 40 percent, and returning it as a tax cut to the top 2 percent. So, you take $1 trillion of support out of health care where it's ending income-based subsidies, turning them into age-based subsidies. And hat ends up hurting people across the board, especially in that bottom 40 percent.

STEPHANOPOULOS: So, given the fact that there are problems right now with Obamacare, what would you do to fix it?

GAWANDE: The biggest things I would do is -- first of all, the aim is that we guarantee that it's good for the patient, right. And the biggest ways to be able to fix that is ensure that you have the average person out there with a $2,500 deductible under Obamacare. We want to be able to open up the subsidies so people have better coverage, that will mean that we continue the plan that secures the insurers to be able to offer coverage under it.

The best way to put it, last year, insurers had made actually a profit by participating in the exchanges. If they have certainty and know that the rules allow them to protect preexisting conditions and offer a minimum benefit coverage, including maternity care and mental health, they're in a place where the market can be restabilized. And then keep Medicaid coverage going. There are 19 states that haven't expanded Medicaid coverage allowing a Republican president to offer Medicaid coverage to the rest of the country would actually make conditions better for us all.

STEPHANOPUOLOS: Dr. Gawande, thanks for your time this morning.

Let's bring this now to the Speaker of the House Paul Ryan. Mr. Speaker, thank you for joining us this morning. A lot to talk about here this morning.

I just want to start out with a big, bottom line question. You just heard Dr. Gawande there. He said that this is going to make health care worse off on almost every level. Can you guarantee based -- if the House bill were to become law -- that no Americans would be worse off than they are today?

REP. PAUL RYAN (R-WI), SPEAKER OF THE HOUSE: I fundamentally disagree with his analysis on so many levels, George.

But, first of all, good morning. It's good to be with you. Second of all, let's remember what is happening right now. Obamacare is collapsing. Obamacare isn't not working. What good is Obamacare for anybody, let alone for a person with preexisting conditions if you don't have a health insurance plan that you can even get.

So this is a rescue mission to make sure that we can achieve the goals we all want, which is getting the cost of coverage down and making sure that everyone has access to affordable health care, especially and including people with pre-existing conditions. That is what our bill does.

So let me just say a couple of things. You have got all of these health insurers. If they were doing so well, why would they be pulling out of the marketplace? Over 1,000 counties, one in three counties in America have one plan to choose from.

Just this week in Iowa, their last statewide insurer said that they are going to have to pull out. So that means people in 94 of Iowa's 99 counties will have zero choices. Aetna just pulled out of Virginia. The law is collapsing. It's not working.

You can't get health insurance in these places, whether you have a pre-existing condition or not. And so what we're trying to do here, George, is step in front of this collapsing law and make sure that we can have a system that works, a system with choice and competition and affordable premiums.

And we have multiple layers of protections for people with pre-existing conditions. So…

STEPHANOPOULOS: Well, let's talk about that, first.

RYAN: … they, too, can have the peace of mind -- so they, too, can have the peace of mind to get affordable coverage.

STEPHANOPOULOS: Let's talk about that first. Because under the amendments that you had, states will now have the option, if they choose, to allow insurers to charge people with pre-existing conditions more.

And you heard Dr. Gawande and others say that in the states where there have been high-risk pools, they have generally been underfunded. And even if you used all $138 billion that you all put in for high-risk pools, that would still cover only a fraction of those with pre-existing conditions.

RYAN: Yes. Can I get you there for a second then?

STEPHANOPOULOS: Yes.

RYAN: So under this bill -- under this bill, no matter what, you cannot be denied coverage if you have a pre-existing condition. And under this bill, you cannot only not be denied coverage…

STEPHANOPOULOS: But you can charge people more.

RYAN: … you can't be charged higher -- let me finish my point. You can't charge people more if they keep continuous coverage. The key of having a continuous coverage provision is to make sure that people stay covered and they move from one plan to the next if they want to.

It's kind of like waiting until your house is on fire to then buy your homeowner's insurance. You want to make sure that people stay covered to keep the cost down. And the most recent…

STEPHANOPOULOS: But…

(CROSSTALK)

RYAN: … that was added…

STEPHANOPOULOS: … sometimes people lose coverage…

RYAN: Just let me finish my point, George.

STEPHANOPOULOS: … through no fault of their own. No, that is one point. I just want to get in on that point.

RYAN: Right. So let me finish my point.

STEPHANOPOULOS: People lose their coverage…

RYAN: And -- that's right. So I was getting there until you just cut me off. The point of this bill in those states that get a waiver to do what they need to do to make it work better in their particular states has support exactly for that very person who, if, in the course between a year, get extra aid for support for pre-existing conditions.

And on the state waivers, they're on the condition that a state has a working high-risk pool to help specifically that person with pre-existing conditions.

Let me give you one example. In Wisconsin, we had a really successful high-risk pool. Ten percent of the people in the individual market in Wisconsin were in the state high-risk pool. They had eight or nine plans to choose from.

They could go to any doctor or any hospital they wanted. And their premiums and co-pays were cheaper than they are under Obamacare today. And the other 90 percent of Wisconsinites in the individual market had better health insurance, cheaper health insurance, more choices.

That is what we want to get to. And you can't say for health care in America one size fits all, one rule for the entire country. Our states are different.

In Maine, they had a invisible risk insurance program, which is the model we use for this bill. And that said that you didn't get a different health care plan, it just -- if you became catastrophically ill, subsidies kicked in and supported your health insurance and your premiums so that you didn't have premium shock.

And what that did is it lowered the cost of premiums for everybody, because if a person gets a catastrophic illness, and state and federal subsidies kick in to support that person, it means all the other insurance plans don't have to cover those eventual costs, and you stabilize that marketplace.

That is the approach we're having here, because our goal is this, George, get everyone access to affordable care, including people with pre-existing conditions. And that is not happening under Obamacare.

Obamacare, the premiums are going up double digits. The deductibles are sky high. And choices are evaporating to the point where one in three counties in America have one insurer left. And now we're learning those last insurers in many states are pulling out.

So this is a crisis. We are trying to prevent this crisis. And we think we have better ideas. And by the way, in Wisconsin, we had a good system. In Maine, they had a good system. Let the states -- because states are different from one another, let the states perfect this while making sure we have multiple layers of protections for people with pre-existing conditions.

We're proud of this. We're proud of this effort. It's us keeping our promises. And it's much better policy than what we're seeing with Obamacare.

STEPHANOPOULOS: There's a lot of uncertainty over what exactly it will do, including in the Senate. Senator Lindsey Graham right after had a tweet saying "a bill finalized yesterday has not been scored, amendments not allowed, and three hours of final debate should be viewed with caution."

And I want to go back to something you said in 2009 when Obamacare was being debated. Here you were on MSNBC.

(BEGIN VIDEO CLIP)

RYAN: I don't think we should pass bills that we haven't read and that we don't know what they cost. If you rush this thing through before anybody even knows what it is, that's not good democracy.

(END VIDEO CLIP)

STEPHANOPOULOS: A lot of your members have conceded they didn't read the bill. There wasn't a single committee hearing or committee markup on the finalized version of the bill. There wasn't a CBO analysis of this bill. So have you met your own standard here?

RYAN: Yes, I think this is a kind of a bogus attack from the left. Let me say a couple of things. The bill has been online for two months. The bill has been --

STEPHANOPOULOS: Not the final version.

(CROSSTALK)

RYAN: -- for a long time.

The final version was an amendment that was three pages long. It takes you 30 seconds to read. By the way, Obamacare was over 2,000 pages. This bill is under 200 pages. It doesn't take long to go through this bill, and the final amendment -- three pages long.

But more importantly, we got two CBO scores. And the most recent CBO score show that we're perfectly in compliance with the Senate budget rules, which is what matters here. And this last amendment, a three-page amendment, is not going to dramatically alter that score. It didn't -- it was narrow changes to the bill. That has been online for quite some time.

STEPHANOPOULOS: Well, in fact, the members who voted for -- the members who changed their vote said there were quite significant changes to the bill. A change to the essential benefits. A change to how you (INAUDIBLE) pre-existing conditions. It added money as well.

RYAN: The last one was -- yes. The last -- it's called the Upton Law and several other members wanted this amendment.

We looked at the whole country and we wanted to see is there a situation, under any situation, with the state getting a waiver, if there is a person that could get charged higher health care costs because of their health status, because of preexisting condition? We looked and decided there might be a situation where, within the course of one year, a person could conceivably get higher health care costs. This amendment affects that.

So we have all these multiple layers of protection to make sure that these families, that these people -- look, these are our friends and our constituents. We will want to make sure people who have bad health care status, who have a preexisting condition, get affordable coverage. And that's not happening in Obamacare. You got to remember, if you can't even get a health insurance plan, what good is it? You don't have health insurance.

So what we're trying to do here is have a system where we have more choices, more competition, and lower prices. And yes, this CBO score does say it lowers premiums. The goal here is two things: Get premiums down, get -- and give people choices. And make sure that people with preexisting conditions get coverage. And we have multiple layers of this.

STEPHANOPOULOS: The CBO --

RYAN: But a one-size-fits-all federal government-run system does not do that.

STEPHANOPOULOS: The CBO analysis also says a lot of other things. It says that, over ten years, 24 million people will lose their coverage. It says for most Americans, deductibles will go up. It says that, for a lot of Americans who are in that age range just short of Medicare, 55-64 years old, particularly in rural areas, they're going to be paying thousands more in premiums every single year. The AARP calls that an age tax.

So if you accept one part of the CBO analysis, do you accept the other part of the CBO analysis as well?

RYAN: Yes, so the first point, the 24 million statistic -- what the CBO is basically saying, and I agree with this, if the government's not going to force somebody to buy something they don't want to buy, then they're not going to buy it. So they're basically saying people, through their own free choice, if they're not mandated to buy something that's unaffordable, they're not going to do it. So under this bill, everybody's going to get a refundable tax credit to buy a plan of their choosing.

But on the age point, you make a good point, which is what Obamacare tried to do, is it said it -- we're going to have younger, healthy people subsidize older, sicker people. That didn't happen. Those young, healthy people just said I'm not paying for this unaffordable insurance. I'll pay the penalty. And that's one of the biggest reasons why Obamacare is collapsing and insurers are losing money and pulling out of the marketplace.

So we're fixing that, and we're also adding money. This was one of their most recent amendments, but it's been out there for a month. Which is we're going to add more money to the tax credit for those people you just mentioned, the people who are 50 and 60 years old. And that's what the Senate is going to do. So that's what Lindsey Graham is talking about, which is we added money to this bill, which the Senate will complete the job, of making sure that the tax credits for those people who are in their older cohorts, 50s and 60s, with a much larger tax credit to reflect those changes, the fact that their health care costs more.

Because what we learned with Obamacare is making younger people buy unaffordable insurance that they can't afford, they're not going to do it.

STEPHANOPOULOS: Well, it sounds like --

(CROSSTALK)

RYAN: And that is why -- one of the reasons why Obamacare is collapsing.

STEPHANOPOULOS: It sounds like, from what you're saying there, is that you wouldn't be comfortable with this bill being signed into law.

RYAN: No, this bill takes $85 billion and adds to it those tax credits. What the Senate's going to do is this specific adding to the tax credits. The Senate's going to say let's figure out exactly how much more of a tax credit a 50-year-old gets and how much more a 60-year-old gets.

So what the House bill did is it took this bill and said we need to add more money to those refundable advanceable tax credits for the older people. And the Senate is going to complete the job of saying just how much more money. And so this is one stage in a multistage legislative process. You know how this works. They pass a bill through the House. Then they pass a bill through the Senate. And then you go to conference and iron out the differences.

And we've already acknowledged we think we need to do even more support for people who are older and also more support for people with preexisting conditions. But gives states the ability to kind of craft and customize health insurance to meet their unique health insurance markets.

Look, I've got to tell you, I know the Wisconsin health insurance market really well. It's a lot different than the New York health insurance market, or the Texas health insurance market. But we have this one-size-fits-all rule from Obamacare that is crashing. It's why insurers are pulling out, people are getting no choices, and premiums are skyrocketing. Premiums went up 116 percent in Arizona in this year alone. So, it's not working. We need to fix this problem, for the sake of just our constituents, or the American people.

People want the peace of mind of knowing they can get affordable coverage, especially for people with preexisting conditions. And quite frankly, George, that's what we're achieving here.

STEPHANOPOULOS: And a lot of people think it is going to be worse.

I want to get another point, though, this bill does cut taxes by about $900 billion. It cuts Medicaid and other subsidies by about $1 trillion. I want to put a chart right now that shows the distribution of those benefits and burdens right now. And it shows that just about everybody under $50,000 is going to be cut back, small benefits for the middle class above that, but a huge, huge benefit for those making over $200,000 a year.

Warren Buffett just yesterday said he's going to get a 17 percent tax cut. And your critics are saying this is just a huge transfer of wealth from the poor and middle class to the wealthy. How do you respond?

RYAN: A couple of things. We're keeping our word, which is we're repealing and replacing the entirety of this law, which is we're repealing all the Obamacare taxes. The Obamacare taxes are job-killing taxes that hurt economic growth and more importantly make health insurance more expensive. These taxes, and most of them are aimed at the health care system, which actually makes those premiums higher. It pushes medical device companies overseas, it makes it more expensive for you to buy your health care. That's point number one.

Point number two.

STEPHANOPOULOS: But most of benefits go to millionaires.

RYAN: Medicaid -- it's -- we're repealing all of the Obamacare taxes. But the Medicaid, what we're doing with Medicaid, we're giving the states the ability to customize Medicaid to meet the particular needs of their vulnerable populations. You've got to remember, Medicaid is a program that is administered by the states, but micromanaged by the federal government, and not very well. More and more doctors are refusing to even accept people with Medicaid. And so we want to give the states the ability to customize the Medicaid program to work for their particular states.

STEPHANOPOULOS: But you're saying they can do that with $880 billion less. You're saying they can do it with $880 billion less.

RYAN: We're -- we're giving states the ability to run their own Medicaid program. And it is increasing for medical inflation.

And by the way, we recognize that for certain people in Medicaid, the disabled, the aged, the people in nursing homes, we're giving them a bigger increase so that their funds are even more than everybody else. And so by giving states the right to run Medicaid, and giving them a block grant, per capita bloc grant, or a bloc grant, and then increasing that the spending by medical inflation, I hardly think that's draconian.

STEPHANOPOULOS: So, you don't think anyone will be hurt when you're taking $880 billion out of the system?

RYAN: No, no, I don't, because I think the micro-management of Medicaid by the federal government. The Medicaid system isn't working. Doctors aren't taking Medicaid, hospitals can't survive with Medicaid alone. So by giving the states the ability to customize their Medicaid population their program to work for them. Whenever we have had a waiver given to a state so they can customize, it works better. So, we want to give every state the ability to make sure that they can customize this program to work for the unique needs of their vulnerable populations.

Again, George, here is the fatal conceit of Obamacare, it says we're going to micromanage this with bureaucrats with Washington telling every state and every community how it must work. That is failing. Medicaid is not working. Obamacare is collapsing. Insurance plans are pulling out. People are not getting no choices, if any at all. And we have to fix this.

This is a rescue operation. And you have to acknowledge, every state is a little different. And so what we're trying to achieve here, and what this bill does achieve, gives states the ability to meet the needs of their populations, but put the resources in there so that everyone can have affordable health insurance coverage.

STEPHANOPOULOS: You talk about state...

RYAN: And micro-managing this from Washington, we've already shown that this isn't working.

STEPHANOPOULOS: You're talking about the state flexibility, Senator Susan Collins is coming up next. She has a bill with Senator Bill Cassidy, that says basically if a state wants to keep Obamacare, they can. If a state wants to experiment, they can. That's state flexibility. What about that bill?

RYAN: Well, I think Susan Collins has made a tremendous contribution to this debate. Again, we want to make sure that we get rid of these Obamacare rules, these regulations, these taxes that are making it impossible for insurers to survive, for plans to be offered. And we want to give the states this kind of things. So, with Maine -- by the way, she comes from a great state which has an invisible risk insurance system which says, we're going to pay for the catastrophic illnesses for people who are catastrophically ill. And what that has done in Maine, is that lower the premiums for people with preexisting conditions. And lower the premiums for everybody else, because we target the support for those people who have a preexisting condition, that is the model that we're copying in this bill.

We think -- look, 1 percent of the people in the individual market drive 23 percent of the costs in health care in the individual market. Five percent drive up almost 50 percent of the costs.

So what we're saying is, let's target our support for that population so that they get the peace of mind and get lower health insurance costs. And that stabilizes the market for everybody else.

Maine has proven how this can work successfully. And so we're looking at that Maine mode model and we're saying, let's do that nationwide. And then if a state like Wisconsin wants to do something slightly different, because Wisconsin is different and unique, let them do that so long as we maintain coverage for people with pre-existing conditioning and give everyone equal access to health care.

You can't be denied coverage if you have a pre-existing condition.

STEPHANOPOULOS: But it doesn't sound like…

RYAN: These are important rules we think that are going to be maintained. And the goal here, I'll just say it one more time, lower prices, expand access and coverage…

(CROSSTALK)

STEPHANOPOULOS: It doesn't sound like a full endorsement of Senator Collins, but I -- one final question. We're just about out of time. I want to ask you a question on the politics.

As you know, the Democrats got wiped out in 2010 after voting on Obamacare. It's one of the reasons you're speaker today, over time. They smell real blood now. You saw Leader Pelosi.

And on Friday, the Cook Political Report, well-respected, shifted 20 seats away from the GOP. Here's what their analyst Dave Wasserman said, he said: "House Republicans' willingness to spend political capital on a promise -- on a proposal that garnered the support of just 17 percent of the public in a March Quinnipiac poll is consistent with past scenarios that have generated a midterm wave."

How worried are you about a midterm wave? What are you telling your members?

RYAN: I'm not. Number one, health care is a complicated and very emotional personal issue. And we completely understand that. The system is failing. We're stepping in front of it and rescuing people from a collapsing system.

And more importantly, we're keeping our word. That's really important here, George. People expect their elected leaders, if they run and campaign on doing something, they expect them to do that. And that's what we're doing. We're keeping our word.

And I would argue that we would spell disaster for ourselves, politically, if that's your question, if we go back on our word. This is us keeping our word. But most importantly, it's us trying to fix a real problem that real people are experiencing in this country.

STEPHANOPOULOS: Mr. Speaker, thanks for your time this morning.

RYAN: Thank you, George.

STEPHANOPOULOS: When we come back, she could be the make or break vote in the Senate. She has big questions about the House bill. Senator Susan Collins joins us live.

And later, our "Roundtable" weighs in on all the political fallout. We're back in just two minutes.

(COMMERCIAL BREAK)

STEPHANOPOULOS: The House has weighed in. Now it's time for the Senate. One of the key votes, Senator Susan Collins, joins us next.

(COMMERCIAL BREAK)

STEPHANOPOULOS: President Trump is up and tweeting this morning. Just out a few moments ago, he said, "Republican senators will not let the American people down. Obamacare premiums and deductibles are way up. It was a lie and it is dead."

We are joined now by one of those Republican senators, Senator Susan Collins from Maine. Senator, thank you for joining us this morning. We just heard the president right there. You heard Speaker Ryan as well.

But you had serious concerns. You were against the original House bill. Is it fair to say you're against the amended one?

SEN. SUSAN COLLINS (R), MAINE: I have a lot of concerns. It's difficult to assess the new House bill because we still don't have a CBO analysis of the impact of coverage and costs. And those are key questions.

STEPHANOPOULOS: Those are the key questions. I mean, we heard Dr. Gawande weigh in on that, as well. But you heard Speaker Ryan right there. He says he's going to take care of those older, rural Americans who don't have the tax credits, who are going to lose their subsidies under Obamacare. He cited your state of Maine several times.

COLLINS: Well, first of all, one of the problems with the House bill is that the tax credits are not adjusted for income or geographic region. That really hurts a state like Maine, where we have an older population living in largely more expensive, rural areas, as far as health care is concerned.

I've heard a lot of talk about the Maine high-risk pool. And indeed, it was a success in Maine for the 18 months or so in which it operated before the passage of the ACA and it can be part of the solution. But in Maine, we had definite revenue streams supporting the high-risk pool, and that is why it worked. In the House bill, it's really up to the states to come up with whatever option they wish.

So that could work and it could be part of a solution. But the devil really is in the details.

STEPHANOPOULOS: So do you agree with the Speaker Ryan and President Trump who are saying people with preexisting conditions are going have the same coverage they have now, even better, Speaker Ryan said, in some cases, letters of protection, than under Obamacare?

COLLINS: I think that's unlikely. But so much discretion is given to the states without any guardrails. The difference between that approach and the approach in the bill that Senator Cassidy and I have introduced is we keep the ACA safeguards, the consumer protections, for people with preexisting conditions.

It's true that under the House bill that a state that gets a waiver would still have to provide coverage to people with preexisting conditions. But that coverage might well be unaffordable. And if the coverage is unaffordable, that doesn't do any good for a child who has juvenile diabetes and is going have that her entire life. And once she's no longer on her parents' policy, that's going to create problems in some states.

STEPHANOPOULOS: If the House bill were before you today, would you be a yes?

COLLINS: Well, first of all, the House bill is not going to come before us. The Senate is starting from scratch. We're going to draft our own bill. And I'm convinced that we're going to take the time to do it right.

Speaker Ryan today said that he hoped that the Senate would improve the House bill. I think we will do so and that we will come up with a whole new fresh approach that solves the legitimate flaws that do exist with the ACA, where with have seen, in some markets, insurers is fleeing so people won't be able to buy subsidized insurance. But it will keep some of the benefits of the ACA.

My goal is to actually expand coverage for those 28 million Americans who still lack coverage today despite the ACA.

STEPHANOPOULOS: A lot of people are struck by the working group that's been put together in the Senate to deal with healthcare. I'm going to put the picture up right there. There you see it right there -- 13 men. Not a single woman. Cecile Richards from Planned Parenthood tweeted about that. "When women aren't at the table, we're on the menu." Senator Patty Murray, Democratic senator of course: "It matters to have women at the table and it matters when they aren't."

Why aren't you on that working group?

COLLINS: Well, the leaders obviously chose the people they want. But I'm working hard with Senator Cassidy, with our co-sponsors, Senator Mike Rounds, Shelley Moore Capito, Johnny Isakson. We're reaching out to moderate Democrats.

I would like to see us put together a bipartisan group to solve this problem, of Democrats who acknowledge that there are problems with the current law, that it is not working well in several states, and Republicans who also want to make sure that we're not reducing coverage and we're giving flexibility.

There's an issue that no one is talking about in Washington that's so critical. And that is if we're going reduce the cost of health insurance, we have to take steps to reduce the costs of health care. And no one's talking about that. Senator Cassidy and I have in our bill a transparency section so that you would actually know what you're paying, and I think that would help consumers make better choices.

STEPHANOPOULOS: Final question, can you support a final bill that denies Medicaid funding to Planned Parenthood?

COLLINS: That is an important issue to me, because I don't think that low-income women should be denied their choice of health care providers, for family planning, cancer screenings, for well women care. It's not the only issue in this huge bill. But I certainly think it's not fair and it is a mistake to defund Planned Parenthood. It's one of many issues.

STEPHANOPOULOS: Senator Collins, thanks for your time this morning.

COLLINS: Thank you, George.

STEPHANOPOULOS: Up next, the Roundtable takes on the politics of health care. Will this week's victory for the White House cost the GOP control of Congress next year? We'll be right back.

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STEPHANOPOULOS: Heard from the House, heard from the Senate. The Roundtable is here. They're going to weigh in next. We'll be right back.

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STEPHANOPOULOS: And we are back with the "Roundtable" right now. Roland Martin -- excuse me, I'm joined here by Matthew Dowd and Cokie Roberts from ABC, former Obama Treasury official Steven Rattner, you heard him, the NewsOne Now host and (INAUDIBLE) Roland Martin, Republican strategic CNBC contributor Sara Fagen.

Welcome to all of you. Lots to talk about here, Matthew Dowd. And I want to start out with that going in political question, big victory for the White House and the Republicans this week.

Will it look like a victory in 2018?

MATTHEW DOWD, ABC NEWS CHIEF POLITICAL ANALYST: Well, I think there's a difference between passing a bill and a victory. And I think those are two separate things in this.

I mean, I'm going to give Donald Trump -- I'm going to say he's right about something. Donald Trump is right that our health care system is broken. And he's right that something needs to be done. But something needs to be done both on affordability and access.

All of us have personal stories in all of this. I have a brother who's a doctor, a sister who's a doctor. I was on the board of a charity hospital. And I had two daughters in the hospital for nine months. Cost $2 million in their care in this. And I think until we fundamentally address -- and this bill doesn't do it; it makes affordability and access worse in this. Until we address those fundamental concerns, the American public is going to keep crying about this.

COKIE ROBERTS, ABC NEWS POLITICAL COMMENTATOR: You know, this question of a victory though. I was struck by Paul Ryan this morning saying I'm proud of this. That could be an ad again him. Because the fact is that, yes, they feel very good that they kept their promises, as he kept saying. And their campaign chairman says, you know, we need to keep our base excited in an off-year election.

Keeping your base excited at the expense of people losing health care I don't think works well politically.

SARA FAGEN, CNBC CONTRIBUTOR: This fires up both bases, no doubt. And I think one of the things that has not gotten as much coverage in this debate over the last week is the fact that the Republican base demanded this.

ROBERTS: Right.

FAGEN: And they demanded it for very good reasons. And Paul Ryan pointed them out, which is Obamacare was failing. And so we can talk all we want about people with preexisting conditions or access to healthcare. But if there's no healthcare system in entire states, essentially, these are all moot arguments because it doesn't exist. So something has to get done.

I've heard very little between Senator Collins and Speaker Ryan that was incompatible.

ROLAND MARTIN, NEWSONE NOW: Are you kidding?

FAGEN: No, no.

(CROSSTALK)

STEPHANOPOULOS: Oh.

FAGEN: You go back and read the transcripts of those interviews. There was only really one disagreement.

(CROSSTALK)

STEPHANOPOULOS: (INAUDIBLE). Hold on a second. I'll take it that they were both careful about that, but if you read between the lines in Senator Collins is going for a bipartisan healthcare plan and more tax credits and no defunding of Planned Parenthood, that's a pretty big difference.

STEVE RATTNER, FORMER OBAMA TREASURY OFFICIAL: Look, I think there's a couple things here. First of all from the standpoint of the Republicans, this could be tough electorally. If you look at the polls, Obamacare, in part thanks to this debate, now polls at a 54 percent approval rating. This bill polls at 17 percent approval. So I think Americans do have concerns.

This thing about preexisting conditions, which is important but not the most important negative change they're making in this bill, has caught a national wave. There's an incredible -- I did one tweet that got 29,000 retweets about preexisting conditions. I've never had a response like that.

Now what the Democrats have to worry about, however, there are problems with the ACA. There are insurance companies are dropping out. Some of those are at the -- some of those are the doings of this administration, which has pulled advertisements, which has done other things to discourage people from signing up and discouraging insurance companies. Some of it is stuff that should and can be fixed if you had legislative support (INAUDIBLE).

MARTIN: George, George --

(CROSSTALK)

RATTNER: But it's something that probably the Democrats have to worry about.

MARTIN: Forget these bases. The Affordable Care Act, the bankruptcies hit (ph) down 50 percent largely because of the Affordable Care Act. And if I'm the AARP and American Lung Association, and the American Diabetes Association, Cancer Association, March of Dimes, you know what I'm doing? I'm holding town halls in those congressional districts saying we're going to tell you actually what's in this bill, how it impacts you. The top ten states Trump won are going to be hurt the most by this House GOP bill. Tell that to the base.

ROBERTS: When you really dig down into it, it gets worse and worse. Because the fact is, is that, you know, Paul Ryan says yes, we are going to cover the preexisting conditions. If you don't lose your coverage. And this bill says that there's no penalty for employers dropping their coverage. So they can drop coverage of people. You lose your coverage and (INAUDIBLE).

(CROSSTALK)

FAGEN: I think everybody needs to take a deep breath on this. Which is that we're through one part of the process.

ROBERTS: Yes, but they voted for it.

FAGEN: They voted for it. It's not the final vote that they're going to take. And what you heard out of Speaker Ryan is that he's looking for the Senate to make improvements. What you heard out of Senator Collins is that the Senate is going to make improvements.

(CROSSTALK)

DOWD: The problem with this is, take the Pottery Barn rule -- if you voted for it, you own it. And it doesn't matter if the Senate fixes this. The problem politically for the House now, a bill now that the majority -- vast majority of the American public does not want.

(CROSSTALK)

FAGEN: The Republicans need to lock arms with what Speaker Ryan said today, which is that if you don't have a healthcare system that's functioning, having one that is functioning, even if imperfect, is far better than one that's --

(CROSSTALK)

MARTIN: Please.

MARTIN: Sara, please, tell somebody with a pre-existing condition to take a breath when they're fighting for their last breath. No, no, no, no, no.

FAGEN: This does not get rid of --

MARTIN: And when you say -- when you say leave it --

FAGEN: This does not get people with preexisting conditions and put them in the dark.

MARTIN: When you say leave it up to the states, we saw what happened when the states did not expand Medicaid. We saw the rural hospitals shut down in North Carolina, in Louisiana, in Mississippi. And I'm telling you right now, whether you are white and broke, black and broke, you live in rural America, you should be scared to death of this bill.

(CROSSTALK)

RATTNER: The one thing we know about this bill is $880 billion is coming out of Medicaid, something like $600 billion is coming out of the subsidies. The CBO has scored this costing as 24 million people their health insurance. That number won't be right, maybe be it's 22 million, maybe it's 26 million, maybe it's 18 million. It's a huge number.

I don't see how Speaker Ryan can say that his bill is fixing a problem.

ROBERTS: Also, they're overstating the business that the health care system is broke. It's not so broke. And the fact is that the Medicaid expansion has really helped health care in the country.

STEPHANOPOULOS: In the meantime, though, it wasn't broke before. But we do have insurance companies now saying they're seeing increases losses with all the uncertainty.

ROBERTS: Some are, some others like Anthem are saying they're doing quite well.

STEPHANOPOULOS: But the longer this debate goes on, the more uncertainty there is.

DOWD: The health care system has been broken for more than 20 years, and it was broke before ACA. And it's broke after ACA. And this fix, it's is like going to a sick patient and giving them experimental treatment, and many experimental treatments hurt the patient. AHCA is going to hurt the patient.

To me, no side is fundamentally addressing, and we need to actually ask the questions should we go to a single-payer system, because affordability hasn't been fixed by this or ACA and accessibility...

STEPHANOPOULOS: That is a huge, huge question. It's not on the table when you have got a Republican House, or a Republican Senate and the White House.

But I don't want to bring one question, though, to Sara Fagen right here. Because it seemed from what you were saying there that now that the House has passed something, it is imperative that the Senate pass something that the House can then pass again and the president can sign.

FAGEN: Yeah, on that we absolutely agree. And I don't disagree my colleagues up here on the politics of this. The politics for Republicans are at this moment pretty dicey. But something needs to get through the Senate that improves on what the House did. And I think Ted Cruz is going to play an absolutely critical role in this, because the Freedom Caucus members in the House are going to watch what he does and how he interacts in this legislative fight. And if they can come together and get something done that improves health care in this country...

MARTIN: How do you improve terrible? How do you improve terrible?

(CROSSTALK)

STEPHANOPOULOS: One at a time.

RATTNER: If you do something that makes Ted Cruz happy, improves it in his direction, you're going to lose Susan Collins, Lisa Murkowski, Rob Portman...

FAGEN: That's not necessarily true.

STEPHANOPOULOS: But, Ted, let me take up on Roland's point, though, right there. You're saying you can't improve terrible. But let's say you're right. Let's say they come together with something that adds money back to Medicaid, puts some more money into the subsidies. Still, CBO comes back and says, OK, it's 18 million, it's 20 million that lose their insurance. Is that something that is defensible?

FAGEN: CBO, first of all, has been very good on the math. They have not been so good in history on reporting on the numbers of people who do or do not have coverage.

But, politically, you know, they're going have to do something, whether it's a grandfather or something -- that does make sure that people who have coverage now continue to have coverage and have good coverage.

STEPHANOPOULOS: But that is the ultimate question. The ultimately question that hurt President Obama.

ROBERTS: If I were a Democratic strategist, I would be focusing all my attention on governors, and because the house is dicey in terms of the districts. And the states are going to have to enact this stuff.

MARTIN: You saw the Oregon governor earlier this week say this is going to leave a $2.8 billion hole in their budgets. To your points, Cokie, when these governors all of a sudden realize that if this bill becomes law, how it's going to impact them. They might have to raise taxes. Trust me, the base won't be so happy.

DOWD: George, to me, substantively the bill is bad. Politically, it's really bad. And so if you take a combination of this bad bill, which we have all seen what happened in 2010, with Donald Trump's approval ratings, the odds of the Democrats taking back the House are more than 50-50 today, which nobody thought that was possible.

ROBERTS: That was true before the...

STEPHANOPOULOS: We're just about out of time. I just wanted to ask you all quickly a yes or no question, does President Trump sign a health care bill this year?

MARTIN: No.

FAGEN: Yes.

DOWD: No.

ROBERTS: Yes.

RATTNER: No.

STEPHANOPOULOS: I think I'm a no, too. We'll see, though. When we come back, the presidential election in France today, did the Russians interfere there as well? We're live if Paris with the latest.

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STEPHANOPOULOS: Voters go to the polls today in France. Big presidential election. Our chief foreign correspondent Terry Moran is on the scene in Paris.

And, Terry, that election, as well, roiled by these last-minute charges of hacking, probably by Russia.

TERRY MORAN, ABC CHIEF FOREIGN CORRESPONDENT: It seems that way. But I have to tell you, George, talking to voters here, they're indifferent. They're dismissive. Some suspicious and angry.

If this was a hack intended to change the outcome of this election, it came too late. And I think because it came after the hack of Hillary Clinton, people are very, very suspicious. I don't think it's going to have that much of an impact.

STEPHANOPOULOS: Let's talk about where the race stands right now. The centrist Emmanuel Macron, been endorsed by President Obama. We saw that endorsement at the end of the week.

Marine Le Pen, the nationalist, has said very nice things about President Trump. They have been aligned on a lot of different issues.

Right now Macron has a huge lead. We have seen surprises before.

MORAN: It is a giant lead right now. The London bookies have him as an odds-on favorite. Turnout is important. And so far today, while turnout is not as robust as it usually is in this country, where French people go to the polls, it is tracking with the expectations of pollsters.

A higher turnout is good for Macron. It is high enough right now, so far, for things to look good for him. There's no question that he is the odds-on favorite today.

STEPHANOPOULOS: Well, let's talk about what that would all mean particularly for the United States right there. Marine Le Pen, of course, riding that nationalist wave as well.

We know if she were to win, she would pull back from NATO. She would pull out from the European Union. We know a lot less about what Macron would mean.

MORAN: Well, he is very much pro-Europe. He wants more European integration. And if Macron should win, you'll have this interesting situation where Angela Merkel in Germany and perhaps Emmanuel Macron in France are really the leaders of that liberal free world that American presidents used to lead, but with Donald Trump essentially backing away from free trade and from other climate agreements and things like that, the internationalist party in the world will be led probably by Germany and France.

STEPHANOPOULOS: You have been covering these elections all across Europe. You think this nationalist wave has hit a wall?

MORAN: It does seem as if the chaos of the early days of the Donald Trump administration has cooled the nationalist populist fervor here and in other countries.

STEPHANOPOULOS: OK. Terry Moran, thanks very much.

We'll be right back this from our ABC stations.

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STEPHANOPOULOS: And now we honor our fellow Americans who serve and sacrifice. In the month of April, four service members were killed in Iraq and Afghanistan.

And that is all for us today. Thanks for sharing part of your Sunday with us. Check out "WORLD NEWS TONIGHT." And I'll see you tomorrow on "GMA."