President Trump’s hilariously candid revelation that “nobody knew that health care could be so complicated” may be remembered as the most succinct summary of the Republicans’ dilemma as they try to fulfill their endlessly repeated promise to repeal and replace the Affordable Care Act. And now that things are about to get specific, what had been a dangerous situation for them is about to turn into a nightmare.
Republicans are set to enter a new phase, in which actual bills are written, debated and possibly even voted on. It’s going to be the equivalent of sticking their heads up out the foxhole so that the other side has something to fix their sights on. If they thought this issue was hard before, they haven’t seen anything yet.
Let’s start with House Speaker Paul Ryan (R-Wis.), who apparently has a plan, one that’s going to go over so well that he’s terrified that anyone might get a look at it:
House Republican leaders have a new version of their major Obamacare repeal and replacement bill. They just don’t want you to see it.
The document is being treated a bit like a top-secret surveillance intercept. It is expected to be available to members and staffers on the House Energy and Commerce panel starting Thursday, but only in a dedicated reading room, one Republican lawmaker and a committee aide said. Nobody will be given copies to take with them.
That’s not the mark of a party confident that what it’s about to propose will be well received. Republicans are facing two problems at the moment, one external and one internal.
The external problem is the public, which has grown increasingly wary of repeal as the possibility has become more real and attention has focused on what would actually be lost if the ACA disappears. Watch an interview with a Republican, and you’ll notice that a few common questions make them squirm. Here are some of them, including the real answers:
- Can you promise that no one who has coverage now will lose it? (No.)
- Can you promise that out-of-pocket costs aren’t going to increase? (Those costs will increase, by design.)
- What does your plan do for people who are on the Medicaid expansion now, many for the first time? (Some might remain on it, at least in the short term, but there are no guarantees how many.)
- What happens to people who still can’t afford coverage after the tax credits you’re proposing? (They’re screwed.)
- Doesn’t your plan make things a lot more complicated for people with preexisting conditions? (Yes.)
- Doesn’t your plan constitute a giveaway to the rich? (Yes.)
Ryan can’t keep his plan secret forever. Once it’s unveiled, we’re going to have a lengthy and detailed debate about it, and those kinds of questions are going to be asked again and again. At some point the Congressional Budget Office will score the bill, and we’ll get a nonpartisan judgment of the wreckage it will cause. That will be a very bad day for Republicans.
When Democrats passed the ACA in 2009, they didn’t pretend that it would create a perfect system without costing anything. But that’s what Republicans are promising now: They claim you’ll have great coverage, with all the flexibility you could want, for less money. Or as the president said in his address to Congress, they will “repeal and replace Obamacare with reforms that expand choice, increase access, lower costs, and at the same time, provide better health care.” And every child gets a pony, while the adults will all have washboard abs, glowing skin and soft, manageable hair.
So far, the public isn’t convinced. The popularity of the ACA has been rising, and members of Congress are being overwhelmed with calls, letters, emails and attendees at their town halls demanding that they not yank coverage and security away from tens of millions of Americans. But it’s important to realize that if they wanted, Republicans could power through all that, even if it represented a political risk. They could say, “This may not be popular, at least in the short run, but we think it’s the right thing to do, so we’re going to do it anyway.” There are some obstacles (particularly the filibuster in the Senate), but they have control of the entire government, and they could make it happen if they were determined enough.
But it would require unanimity on the particulars of what repeal-and-replace looks like — which brings us to their internal problem. Right now they can’t agree on what a replacement should be, and the disagreements aren’t minor at all. It isn’t as though one group of Republicans thinks there should be a $4,000 tax credit for people to buy insurance, and another group thinks it should be $5,000. The disagreements go much deeper.
For instance, Freedom Caucus members in the House (the chamber’s most extreme conservatives) have threatened not to support any bill that doesn’t repeal the ACA’s expansion of Medicaid, which has resulted in around 14 million additional poor Americans getting covered. Your average Republican doesn’t like the Medicaid expansion either, but many of them also realize that now that all those people are covered, kicking them off would be a political (not to mention a humanitarian) disaster. For example:
“I’m very concerned about [a proposal] that would repeal Medicaid expansion,” Sen. Shelley Moore Capito (R-W.Va.) said Wednesday. “I don’t think we’re going to go that direction. I hope not, in the House or here, but that would be a major source of concern for me.”
Asked if she is concerned about the House plan, which would repeal the extra federal money for Medicaid expansion, Capito said, “Yeah, I mean we need the extra federal money.”
Sens. Dean Heller (R-Nev.), Lisa Murkowski (R-Alaska) and Rob Portman (R-Ohio) also have concerns about repealing the Medicaid expansion. Three of them voting no would be enough to sink a bill in the Senate.
But conservative senators, who demand that the Medicaid expansion be repealed, also have enough votes to sink a bill. Sens. Ted Cruz (R-Texas), Rand Paul (R-Ky.) and Mike Lee (R-Utah) say that Republicans must vote again on the sweeping repeal bill passed in 2015, which did away with the Medicaid expansion.
What do West Virginia, Nevada, Alaska and Ohio have in common? They all accepted the law’s expansion of Medicaid, so those members’ constituents are at risk. And that’s not all. Cruz, Paul and Lee also object to a provision in the emerging plan that would replace the ACA’s subsidies for middle-class people with tax credits that could be used to buy insurance. Even though the tax credits would be far less generous and wouldn’t be given according to income (so Bill Gates would get the same credit that someone of his age working at McDonald’s would), that’s still too much for those conservatives, who consider it an “entitlement” that violates their small-government principles.
So you’ve got ultra-conservatives who aren’t willing to accept a half-measure (backed up by right-wing pressure groups) at odds with ordinary conservatives who’d like something that minimizes the upheaval and political risk of repeal. Their differences look irreconcilable, and if either group bails, repeal is dead. It’s even possible that what Ryan and other leaders come up with will be unacceptable to both groups, losing support from both the right and the left within the GOP. If there’s a solution to that conflict, no one seems to have located it yet.