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Some whats and whys of the current moment in the health-care debate

Senate Majority Leader Mitch McConnell of Ky. arrives on Capitol Hill in Washington, Monday, July 17, 2017. AP Photo/Andrew Harnik

“What a difference a day makes, 24 little hours,” and two senators. Assuming you’ve had a chance to peruse your morning paper, you know that Senate Majority Leader Mitch McConnell (R-Ky.) now lacks the votes to pass the latest version of his bill to repeal-and-replace Obamacare. Once Republican Sens. Mike Lee (Utah) and Jerry Moran (Kan.) joined Sens. Rand Paul (Ky.) and Susan Collins (Maine) in opposition to the bill, McConnell had no way to get to 50.

Truly, this is a weird and portentous political moment. For the seven years since the Affordable Care Act’s enactment in 2010, a core tenet of American conservatism has been to take it down. How could it be that with Republicans now controlling all three legislative branches, they thus far have been unable to pull it off? And what might the future hold?

The second question is harder, so let’s start there. Warning: pure speculation ahead, so I won’t dwell on this part. But the options, as I see them, are:

— Try to do what the House Republicans did when their (nasty) reform bill failed the first time: tweak and retry. But the Senate has already done so, and given the razor-thin vote margins, it looks like an unsolvable Sudoku problem. Tack toward a less punishing bill, you lose the hard right, and vice-versa. Thus, the one thing I feel pretty confident about here is that the Senate bill as we know it is dead. (You’re only supposed to say good about the dead, so I say: That’s good!)

— Start from scratch and come up with a new repeal-and-replace bill. I really don’t see them pursuing this option, in part because they really want to move on to tax cuts. Moreover, they must realize both the Sudoku problem noted above along with the many reasons I get into below as to why this whole endeavor is so tricky for them.

— Just plain repeal Obamacare as per their pledges to their base and be done with it. Though such a vote would be unlikely to pass — supporters would surely be blamed for much worse coverage and premium outcomes than those that contributed to the failure of the Senate’s replacement bill (repeal would double the number of the uninsured) — I can see where it would have some appeal. A failed vote would bring some closure and perhaps give the Republicans the path out of this morass and onto tax cuts, which has always been their primary goal. A variation on this one is to raise the possibility of a repeal vote, as they’ve already done, and once it looks impossible, just wash their hands of the whole issue and move on.

— Work with Democrats to improve the shortcomings of the ACA. I know: I must be dreaming, but a rational response would be “Obamacare is here to stay, so let’s figure out how to make it work better for people, especially those in the exchanges and those stuck in states that didn’t take the Medicaid expansion.” More likely, they’ll continue to sabotage the program by undermining coverage mandates and flirting with the removal of cost-sharing reductions.

But how is it that we’re at an “options” moment? What makes it so hard for Republicans to accomplish one of their key goals?

I can think of a least three fundamental problems. One, they’ve painted themselves in a tight corner with the top 1 percent, two, they’ve got no policy bench or vision on health care beyond killing Obamacare–they get “repeal;” they congenitally don’t get “replace”–and three, there may be no other issue where the gap between their rhetoric and their policy is so blatantly wide.

For many, repealing Obamacare was always about rechanneling its revenue-support back to the richest taxpayers, drug companies and insurers. But such tax cuts are a lot easier to pull off — in fact, I expect they will eventually succeed in this part of their agenda — when they’re not directly attached to taking away a concrete benefit, i.e., health coverage, from low- and moderate-income people.

That’s why those Congressional Budget Office scores of their plans have been so devastating. It’s one thing to say, “the vast majority of the benefits of the tax cuts go to the top.” That skewed distributional complaint has long dogged Republican tax plans — I know because I’ve made it and will continue to do so. But it’s another thing to expose the reverse-Robin-Hoodism of simultaneously cutting rich people’s taxes and poor people’s health insurance. (To be clear, the new House budget resolution does the same thing. This battle is so far from over.)

Meanwhile, President Trump, as is his wont, promised people more for less. Reform would yield comprehensive, cheaper coverage than Obamacare. It was a lie, of course. He’s never had anything like such a plan. And it might have worked — it might still work — but for the fact that the ACA is already in place providing coverage to at least 20 million people who didn’t have it before.

Think of it this way. Trump can go on all day about bringing back coal jobs, and even though the economic reality is that he won’t be able to do so, such claims don’t hurt him, as they signal support for a group that’s been left behind and ignored by everyone else. However, if he then got behind legislation to wipe out the remaining coal jobs, the legislative dissonance would look a lot like what we see with health care.

Finally, as I wrote on this page just yesterday, the Republican caucus willfully refuses to understand government’s role as an insurer in areas where the market tends to fail or be incomplete, such as health care, retirement security, anti-poverty policy and financial deregulation. Again, such an understanding is inconsistent with their tax-cuts-for-the-rich agenda.

Thus far, Republicans’ efforts to repeal and replace have run smack into these contradictions. They propose to seriously hurt some of the very people who helped put Trump in the White House so that they can partially offset the costs of wasteful tax cuts for the rich. They say they want to help the disadvantaged, but their actions betray such claims, and their falsehoods have been most clearly exposed in this health-care debate.

There may still be enough representativeness left in our democracy to block such venal efforts. But then again, there may not. Stay tuned.