Monday, July 31, 2017
How Republicans Got Stuck on Repeal
by Jennifer Haberkorn
Republicans openly speculated in November whether they could fast-track an Obamacare repeal bill to Donald Trump's desk by Inauguration Day or whether they might need just a few days longer.
But Congress got stuck. Its last-ditch attempt to pass a "skinny" bill to kill a few pieces of the health care law — many of which the president could have abolished himself with an executive order — collapsed.
In the intervening six months, Republicans were bedeviled by an enormous backlash from a public that suddenly decided it likes the health care law, cold feet over stripping health care coverage from millions of Americans, damaging intraparty squabbling and a White House that threw bombs at their efforts. Ultimately, an old truth held: Once politicians bestow social benefits, it's almost impossible to take them away.
Now that Republicans have failed to repeal former President Barack Obama's signature domestic policy achievement, the GOP faces an existential Obamacare problem with no immediate answer. Do they keep trying to undermine it, as they've promised for seven years? Or do they try to make it work better — even if that means compromise with Democrats?
Trump pressed the GOP all weekend to keep at it. "Unless the Republican Senators are total quitters, Repeal & Replace is not dead!" he tweeted. "Demand another vote before voting on any other bill!" He even taunted lawmakers by threatening to take away their health care benefits if they don't deliver. On Sunday, his health secretary, Tom Price, refused to rule out a move to stop enforcing the requirement that people get covered.
But if these six months have taught Republicans anything, it's that their party's divisions over how to repeal and replace the Affordable Care Act are deep and systemic.
Repeatedly through the arduous process of passing legislation in the House and getting tantalizingly close in the Senate, the same problems kept reemerging — including public resistance to gutting protections for pre-existing conditions or rolling back Medicaid. They show no signs of resolution as the GOP seeks a path forward.
"It's complicated," said Sen. Rob Portman (R-Ohio), one of several Republicans who echoed Trump when asked why the GOP can't come together on Obamacare. A pragmatic Midwesterner, Portman was among the Republicans caught between their campaign pledges to undo Obamacare and governors who don't want their Medicaid expansion funds wiped out. "It's tough to get to a solution," he said.
At the start of the year, Republicans planned to spend no more than a few weeks on repeal, maybe even having legislation ready for Trump's signature when he took office on Jan. 20. They would use a bill that was crafted by conservatives in 2015, passed by both the House and Senate — and vetoed, as expected, by Obama.
That vote wasn't just symbolic. It was a test run for this very moment when a Republican occupied the White House. The bill would repeal Obamacare's most unpopular provisions, like the individual mandate, but had a two-year delay built in, giving Congress time to develop a replacement.
But the once-steely resolve to undo Obamacare "root and branch" eroded fast. Rank-and-file lawmakers refused to do repeal without an immediate replacement. They couldn't agree on how much to repeal — or what to replace it with.
"I don't think the American people will understand it if we say we're going to cancel your insurance and just trust us in the Congress to come up with a replacement," said Sen. Lamar Alexander of Tennessee, one of six Republicans who supported the repeal bill in 2015 but opposed it last week. "Most pilots like to know where they're landing before they take off."
With a new goal to get a bill to Trump's desk by his 100-day mark, House Republicans tried to craft a plan that killed enough of the law to satisfy conservatives but not so much to drive away an unusually assertive bloc of moderates.
The rift was too great. Speaker Paul Ryan pulled the bill in April and declared Obamacare the "law of the land," echoing the comments his predecessor John Boehner made after Obama's reelection, words that in retrospect signaled the beginning of the end for Boehner's speakership.
That first taste of defeat on Obamacare repeal was powerful. The bad headlines and fear of backlash from their base drove moderates and conservatives back to negotiations. Some now wonder whether history could repeat itself in the Senate.
By early May, the House passed a bill in part because of a last-minute moderate-conservative compromise, and partly because of an unorthodox pitch to squeamish lawmakers: Just vote to advance the bill one step closer to Trump's desk. The Senate will fix it.
But Republicans never really liked the policy they were voting on, and everyone knew it would land with a thud in the Senate.
"There is no constituency for the bill," said one Republican senator who was deeply skeptical of the repeal effort. His constituents still liked the idea of repealing Obamacare and supporting the president — but they weren't calling his office to say they liked the bill.
At first, it looked like Senate Republicans might have a chance at doing better. Alexander, a moderate who chairs one of the key Senate health committees, teamed up with Sen. Ted Cruz (R-Texas), the conservative firebrand who had shut down the government in a failed bid to stop Obamacare in 2013. They assembled a group of 13 senators — originally all men, but later expanded to all Republicans — who might be able to find the formula that could get 50 of the 52 Republican senators needed for passage. Vice President Mike Pence could break a tie.
But two key policy issues divided the GOP in both the House and Senate — and still exist today: Obamacare insurance market regulations, including those protecting pre-existing conditions. And Medicaid.
Conservatives were adamant that to reduce premiums, they had to eliminate Obamacare's rule that insurers cannot deny coverage to people with pre-existing conditions. But moderates worried about the political price of undoing one of the ACA's most popular provisions.
Medicaid was also a sticking point, particularly in the Senate. Part of the problem was conservative overreach; the repeal bills went beyond Obamacare Medicaid expansion, fundamentally changing federal financing of a health care program for the poor that's been in place for 52 years. Governors in both parties were alarmed.
And even the Obamacare part of Medicaid pitted lawmakers from states that had taken billions of federal dollars to expand coverage against those that had not. The Senate was never truly able to come up with a solution that satisfied senators or their governors.
"I'm very frustrated," Sen. David Perdue (R-Ga.) said shortly before the Senate vote. "There are some people here who are ... holding out for their little piece of [a policy win], and that's not serving the national interest." Georgia had not expanded Medicaid, and it didn't want to pay for that decision for years to come.
In the end, Republicans weren't able to agree on much other than ending the individual and employer mandates, defunding Planned Parenthood for a single year and giving states more flexibility — some of which Trump and his Department of Health and Human Services can grant without legislation.
At 1:30 a.m. Friday, Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) — longtime critics of the repeal effort — and John McCain (R-Ariz.) — a surprise — voted with Democrats. For now, at least, the effort is dead.
Democrats won't back down in their defense of the health care law. It has endured life-or-death Supreme Court cases, a catastrophic rollout in 2014 and, until last year, several election cycles that only sharpened the public divide. The dark-of-night showdown in the Senate may have been its most serious brush with death.
But the Republican repeal effort hasn't died, either. It, too, has been resuscitated time and again, despite the court defeats and Obama's reelection. It's not clear what comes next — but something will.
"This health care bill," Sen. Steve Daines (R-Mont.) pointed out when the Senate managed to get debate started last week, "has nine lives."