If there's anything we've learned from the Republicans' campaign to repeal the Affordable Care Act, it's that rumors of its death tend to be premature. Still, with Sen. Susan Collins (R-Maine) having provided the crucial third GOP vote in opposition, the 2017 effort seemed finally to have entered the hospice stage on Monday.
Senate Republicans were to meet Tuesday to decide whether to declare the patient terminal. Under those circumstances, a post-mortem may not merely be timely, but almost an act of mercy. So let's examine why the Republicans' attack on the Affordable Care Act kept running into a brick wall. That's not to say that they won't try to keep hitting the same wall; talk has already begun on Capitol Hill about how to revive the campaign after this week.
[UPDATE: The Senate leadership has canceled plans to vote on an Affordable Care Act repeal bill this week, almost certainly ending the repeal effort for this year.]
It's always tempting to declare the outcome of any contest preordained, even when it was closer than it looks. One side's victory in the World Series or a presidential election often is treated as inevitable in retrospect, though a single timely hit or strikeout or the shift of a few thousand votes in a couple of states might have been the determining factor. With repeal, however, failure was baked into the outcome from the start.
With control of the White House and both houses of Congress in its hands, the GOP could have nudged a repeal bill into law. But the chances it would actually improve America's healthcare system were nil, and that became a major obstacle. Let's unpack the reasons why.
Start with the big picture. Major legislative efforts always start by defining the goal — the Point B one wants to reach from Point A. Then the question becomes how to get from A to B, and the process of negotiation and compromise can start.
On Affordable Care Act repeal, the Republicans never have defined a Point B, at least in terms of a vision of American healthcare. In part, that's because the issue never has been high on the party's agenda. As a result, Republican healthcare policy is almost always defined in terms of the party's other priorities — free-market competition, lower taxes, devolution of regulation to the states, defunding of Planned Parenthood. Beyond that, the umbrella definition of the GOP's healthcare policy was "not Obamacare."
But do the Republicans favor universal coverage? A hybrid public-private payer system? And whether regulation is managed at the state or federal level, what should be regulated and by how much?
Over the last few months, Republican leaders never even aired these issues. Their Point B became passing a repeal bill — any repeal bill — and their justification became making good on a seven-year promise to repeal Obamacare. That's what Sen. Chuck Grassley (R-Iowa) was talking about when he explained last week, a propos of why the Senate should pass the egregious Cassidy-Graham repeal bill, "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."
Republicans have tended to pay lip service to some positive healthcare principles that have popular support, such as lowering premiums and protecting people with preexisting conditions. But without a vision of how these elements fit into the healthcare system as a whole, much less the compromises necessary to achieve them, they're easily discarded. According to every independent analysis, Cassidy-Graham would have driven premiums higher (or moderated their rise by paring away insurance benefits), and eliminated the Affordable Care Act's protection for those with medical conditions.
By shifting their goal from reforming the nation's healthcare system for the better to passing any bill that could be labeled "repeal," the GOP made things easier for itself in one sense. It absolved itself from the need for hard work.
GOP hobbyhorses on healthcare always have had a once-over-lightly flavor. Republicans have pushed for tort reform, based on the claim that "frivolous lawsuits" and defensive medicine are major contributors to high healthcare costs. But they're not: Malpractice litigation contributes a couple of percentage points to total U.S. healthcare costs. And shutting the courthouse door to malpractice litigants requires major tradeoffs — victims of genuine malpractice lose their recourse, especially if they're children and women, and an important check on physician behavior disappears.
Another Republican shibboleth is selling health insurance across state lines, ostensibly to increase competition and therefore reduce premiums. As we observed last year, this is a vacuous idea, encrusted with myths. The most important myth is that it's illegal under Obamacare; the truth is that it's specifically enabled by the Affordable Care Act. Another truth is that neither state regulators nor insurance companies are interested and consumers, doctors and hospitals don't care. The main reason is that selling insurance across state lines is vastly more complicated, and less profitable, than Republican officeholders know. Like tort reform and defunding Planned Parenthood, cross-state insurance sales is a slogan, not a policy.
But making healthcare policy is very hard, because the field is incredibly complicated. Not merely does healthcare account for one-sixth of the U.S. economy, but every piece of it interacts with the rest. Reduce premiums, and deductibles go up. Require that people with preexisting conditions be charged the same as everyone else, and you have to mandate that everyone have insurance; remove that mandate, and insurers will avoid covering people with preexisting conditions by abandoning the marketplace. Shrink the list of essential benefits required of every health plan, and women of childbearing age won't be able to buy maternity coverage.
And that's just at the retail insurance level. The Affordable Care Act also regulates how hospitals admit and discharge patients, how doctors and hospitals get paid, how novel therapies and medical devices get judged. And much more.
Navigating these shoals requires expertise and time. It can't be done on a tight deadline, and without the development of a solid storehouse of information. As my colleague Noam Levey has reported, Medicare was developed and debated for eight years before its enactment in 1965. The Affordable Care Act was debated and analyzed for more than 15 months before President Obama signed it into law in 2010 — after 79 hearings in the House and 100 in the Senate. Cassidy-Graham received a single hearing in the Senate — a raucous event on Monday, hours after its final version was released.
It's often said that the Republicans avoided hearings on their repeal bills because they wanted them kept secret until the last minute. But it's also possible that they realized that once they opened the Pandora's Box of healthcare complexity, it would take years to corral all the questions raised.
Not having bothered with constructing a factual case for repealing the Affordable Care Act, Republicans have resorted instead to lies and misrepresentations. House Speaker Paul Ryan (R-Wis.) insisted this summer that there were dozens of counties in the United States without a single insurer in the Obamacare exchange market, when the actual number was one; a few days later, the number dropped to zero.
Ryan, President Trump, and others repeatedly cited a 116% increase in gross premiums in Arizona for 2017, but failed to mention that (1) Arizona was a massive outlier, and that the nationwide average was 22%; (2) that in 2016 the state had had the second-lowest average premiums in the nation, and therefore insurers were making up for underpricing in the past; and (3) subsidies for Arizona buyers had risen by an average of more than 400% for 2017, insulating most of them from the increase.
The Affordable Care Act's critics have continually maintained that the system is collapsing; at a CNN debate Monday featuring Sens. Bill Cassidy (R-La.), and Lindsey Graham (R-S.C.), the authors of the latest repeal bill, and Sens. Bernie Sanders (I-Vt.) and Amy Klobuchar (D-Minn.), Graham repeated this mantra. "I'm here tonight because Obamacare is failing," he said.
But to the extent that's so, it's because the Trump administration has been undermining the program since it came into office — holding insurance subsidies hostage, cutting funds for marketing and outreach, and discouraging enforcement of the system's individual mandate. Analyses by Standard & Poor's and the Congressional Budget Office have established that the marketplace was stabilizing before Trump tampered with it.
That's a sign that the effort to kill the Affordable Care Act isn't really over — it's just moved from the legislative branch back to the executive. The most aggressive enemy of the Affordable Care Act today is Tom Price, who as secretary of Health and Human Services is the government official responsible for making it work. Is he doing his job?
In a word, no. Under his aegis, the open enrollment period for users of the federal exchange, HealthCare.gov, will have only six weeks to sign up for 2018 coverage, rather than the traditional three months. With advertising and outreach funding cut by 90%, many buyers may not learn that their deadline is Dec. 15, not Jan. 31. HHS recently announced that HealthCare.gov will be shut down for servicing for 12 hours every Sunday but one during open enrollment, a transparent step to discourage signups.
Last November, on the day after the election, we observed that even with control of Congress and the White House, the GOP would find it very hard to repeal the Affordable Care Act — but easy to vandalize it. With the apparent collapse of the repeal bill in the Senate this week, the first part of that observation appears to be coming true. But the second is very much alive.
It's sometimes said that the administration is out to "sabotage" the Affordable Care Act. But that's giving them too much credit. Saboteurs typically have a purpose in mind — to win a battle or a war. This administration can't say why it wants the Affordable Care Act to work worse, or what it hopes to gain from driving up costs and dangling coverage out of the reach of millions more Americans. That's what defines vandals — they destroy, but for no sane reason at all.
11:55 a.m.: This article was updated with the announcement that the Senate GOP leadership has canceled plans to vote on an Obamacare repeal this week.