Let me briefly try to answer this question: How did Republicans fail to repeal and replace the Affordable Care Act? In no order, and off the top of my addled mind at the end of a crushing week:
— They hated Obamacare but they never understood the Affordable Care Act. This is the uber-explanation for much of what follows. Hating Obamacare became just what you did on the right. It didn’t mean you understood it, beyond maybe getting that it was a government program and thus paid for by taxes. It certainly (and this turned out to be very important) didn’t mean you had any ideas about what it did, how it worked or how many people were benefiting from it … or how to replace it.
— Obamacare created a new baseline. It’s hard to take away something — in this case, health insurance coverage for more than 20 million people — from which people are benefiting. This relates to the above — because they didn’t understand the law, they convinced themselves that calibration problems, of which there were many, were fatal. So, when premiums rose sharply in some of the exchanges, they didn’t understand that most exchange recipients wouldn’t see anything like those increases (due to the subsidies that adjusted to meet the higher costs). They didn’t recognize that less than 10 percent of those with coverage get it through that part of the market. Millions more get Obamacare coverage through the Medicaid expansion, and they convinced themselves that this was a terrible part of a program that no Republican governor or member of Congress would ever want to keep in place.
— They don’t have a policy bench. From Trump on down, many of today’s conservatives tend be much more skilled at campaigning, opposing pretty much everything, riling up their bases with antipathy toward the other side and getting elected (granted, that last bit’s kind of important) than at the qualities that enable governing, like compromise and fact-based analysis. Of course, there are thoughtful conservatives with cogent ideas about health policy, but clearly they’re of little interest to today’s leadership. How do I know that? Because their replacement law — the American Health Care Act — was an incoherent dog’s breakfast of massive tax cuts for the rich and spending cuts for the poor, more a caricature of Republican policy than actual policy. In this regard, credit also goes to the Congressional Budget Office, for quickly and credibly revealing the damage that would be done by the AHCA.
— The one policy Republicans get is tax cuts, and little else motivates/interests them. This is a variant on the previous entry, but it meant that a real motivation for the repeal was cutting about $1 trillion in taxes, including two ACA taxes paid mostly by the wealthiest Americans. It is axiomatic that when you cut such highly progressive taxes, the benefits go to those at the top of the scale, and it quickly became clear that, for example, almost 50 percent of the cuts went to millionaire households. The 400 richest taxpayers, with average income above $300 million, would get a tax break averaging $7 million. Couple that with the sharp cuts in Medicaid and the predicted premium increases for low-income elderly people in their AHCA plan, and even in D.C., the extent of this Robin-Hood-in-reverse play was too much for moderate Republicans, many of whom have ACA beneficiaries in their districts from whom they were hearing.
— They’re ungovernable. It caught my attention when former House leader John A. Boehner predicted what just happened a few weeks ago. Part of this was a variation of the “no bench” point above: “In the 25 years I served in the United States Congress, Republicans never, ever, one time, agreed on what a health-care proposal should look like. Not once.” But part was an impossible political Sudoku problem that House Speaker Paul D. Ryan couldn’t solve: If you try to please the moderates, you lose the hard right. Boehner learned that lesson in must-pass votes, like raising the debt ceiling, that he passed with votes from Democrats, which wasn’t going to happen here.
— President Trump wasn’t much help. When I worked for Obama during his first administration, I vividly recall two challenges in moving legislation: Republicans and Democrats. From day one, the R’s were never with us, but we also quickly learned that it would take a ton of work to woo our own caucus. I don’t think team Trump is there yet by a long shot. Moreover, he’s got some unique problems of his own making: People are learning his “art-of-the-deal” shtick, so they know that what he says Monday may well be totally different from where he is Tuesday.
— Their version of reality did not allow for the ACA gaining public support. Various polls, including this one from Pew, show public support for the ACA hitting its highest level on record, with 54 percent approval and 43 percent disapproval (see Figure 3 here as well). Their bubble also seems to have kept them from realizing that their replacement bill was in terrible shape re: public support. Before they pulled the vote on Friday, former Republican House Speaker Newt Gingrich, of all people, was compelled to tweet out the following: “Why would you schedule a vote on a bill that is at 17 percent approval? Have we forgotten everything Reagan taught us?”
Readers of this column know my extremely negative take on their replacement bill, so of course I’m very glad about this outcome. But we’re not out of the woods, in part because the ACA is far from perfect and I don’t expect this government to provide it with the maintenance it needs. Also, while I know that Trump said that if this vote fails, there will be no trips back to this well, recall what I said above about the veracity of such announcements: No one should believe them.
But at least so far, I was wrong when I bemoaned late on the night of Nov. 8: “There goes the ACA.” It’s still standing, and for millions of Americans with affordable coverage, that is a very good thing.