GOP futility on health care is complicated, but simple: They don’t agree

Obamacare is a pretty unimpressive program. It continues to limp along with low participation rates, narrowing options, and rising costs. Insurers on the exchanges will once again seek huge premium increases, and once again we’ll be left wondering why it’s called the Affordable Care Act.

All of this is true, yet near-unanimity about Obamacare among Republicans hasn’t led to any action on replacing it. The GOP’s approach to the health care issue, this year and previously, has been a complete soup.

Restive Republican voters are willing to chalk this up to Congressional Republicans’ fecklessness, or assign craven motives to Mitch McConnell and Paul Ryan. The reality is simpler: Congressional Republicans don’t agree on what the health care market should look like in this country.

It’s pretty tough to pass a bill when not enough people agree, when there’s no consensus on how to move forward.

Unseemly history
You’ve got to hand it to the Democrats, in 2009 and 2010 they stuck together to move the health care issue in the direction they wanted it to go. Obamacare went farther than some were comfortable with, while other Democrats thought it was not nearly radical enough. Most voted for it anyway.

That’s not to say their actions to pass health care reform were admirable. The House passed it in a late night, party line vote, in a process where you had to vote for the bill “so that you can find out what is in it.” The Senate then had to re-approve the bill through the unusual reconciliation process. Republicans rightly howled at 1/5 of the national economy being overhauled in such a chaotic, secretive way through sheer power politics.

Now, Republicans are doing (or at least attempting to do) the same things. Consider:

  • “Obamacare was passed while most of the country was asleep, and Congress didn’t even have time to read the bill before they voted for it.” Now, the latest GOP bill (Graham-Cassidy) is being rushed through before a Sept. 30 deadline. It’s not being routed through health care committees but instead, if it receives a hearing, it will be in the Homeland Security and Governmental Affairs committee. The Congressional Budget Office will have no time to do a rigorous analysis on the bill before the vote (Sen. John McCain’s announcement today might make all of this irrelevant, but it still looks pretty bad).
  • “Obamacare was passed on a party line vote, and Democrats made no attempt at bipartisan cooperation.” Today, Congressional control has flipped but nothing has changed. You can view this as “what goes around comes around,” but the GOP is now doing what it complained was unconscionable seven years ago.
  • “The Cornhusker Kickback is corrupt dealing at its worst.” Republicans were right to complain about the sweet deal offered to Nebraska to entice Ben Nelson, the Democratic senator from that state, to vote yes on Obamacare. I even considered a lawsuit over it, before the deal went kaput. Now, Republicans are trying to woo Alaska Sen. Lisa Murkowski with Alaska-only provisions.

Again, Republicans aren’t divided on “repeal” – it’s “replace” where it all breaks down. In 2012 I was briefed from time to time by someone in the thick of GOP health care talks in Congress. Every time the question was raised of what consensus was building in D.C., what plan Republicans were coalescing around, the answer was the same: “They don’t agree.”

Five years later, they still don’t. Some are wary of disrupting Medicaid in their home states, while Sen. Rand Paul won’t vote for a bill that leaves so much health care power in government’s hands. He calls Graham-Cassidy “fake repeal.”

The art of the deal
President Trump’s ever-shifting views on health care haven’t helped. He campaigned on protecting Medicare and Medicaid but backed earlier repeal efforts that included cuts, and has seemingly gone back-and-forth several times. He’s hunting for a “deal” but doesn’t actually know what he wants.

Further complicating matters is the fact that some of the more popular parts of Obamacare are the biggest cost drivers. Community rating is popular with older exchange customers, but it drives up premiums for everyone else (and helps keep younger customers out of the market, which also raises premiums). Rules on not barring those with pre-existing conditions (guaranteed issue) are likewise popular, but they too increase prices significantly.

Health care is complicated. This is news to some. Sen. Lindsey Graham sees “taking your best shot” to repeal and replace as preventing the death of the Republican Party. Sen. Chuck Grassley, who is known for his forthrightness, said this week, “I could maybe give you 10 reasons why this bill shouldn’t be considered…But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

But a quote from Graham last month, on an earlier effort, sums up the last seven years of Obamacare futility: “The bottom line is we didn’t fail because we didn’t have enough time. We failed because we were not ready to solve the problem, and we didn’t have the right idea.”
-Rob McKenna

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Rob McKenna
Rob served two terms as Washington’s Attorney General, from 2005 to 2013. He successfully argued three cases before the U.S. Supreme Court and negotiated three of the largest consumer financial protection settlements in national history, all involving mortgage lending and servicing. He is a recognized leader in the development of consumer protections on the internet, in data protection and privacy regulation.