100 Days of Health Care
Before November 8, no one anticipated that health care would be the predominant focus of the next president's first 100 days. Now, let the record reflect, that is precisely what has happened.
What have we learned in the process and what do we have to show for it? The latter question is easier to answer: nothing, save for considerable uncertainty and burgeoning disruption for the health care system. As for the former, Republicans have hoisted their own petard in epic fashion.
After spending seven years promising and repeatedly voting to repeal Obamacare, Republicans felt they had a clear mandate - in the truest sense of the word - to finally execute their goal.
But somewhere inside many key Republican leaders, if not the President, was a sinking realization that repeal of Obamacare's numerous new benefits and protections would be difficult, deeply controversial, and perhaps morally regrettable - in a word: "complex." As a senior congressional aide once put it to me, "the dog had caught the ambulance."
The campaign started as most daunting legislative battles do: the offense beats a steady drum of inevitability, hoping to intimidate potential opponents into submission before a meaningful defense can be mounted. That worked, for a while.
Only when details of the so-called repeal and replace bill, the American Health Care Act (AHCA), became public did meaningful objections begin arise. It started with some governors, who had been invited to comment on potential changes (read: cuts) to the Medicaid program, a federal-state partnership that covers 78 million people nationwide.
Shortly thereafter, hospitals and patient groups began to protest, later joined by other health care stakeholders and, by Congress's President's Day recess, the public at large. Town halls filled up and support for repealing Obamacare cratered.
The heart of the problem: the repeal bill didn't do a single thing to actually help anyone, and it would harm a great many. Tens of millions would see their coverage stripped while everyone else, even those with employer insurance and seniors on Medicare, would see their costs go up. Consumers would have fewer choices and those with preexisting conditions would be unprotected.
Only later did we learn the real reason why the health care implications of the bill were so ill conceived: the underlying motive for it is to lay the groundwork for tax reform. By repealing the Obamacare taxes, Republicans could achieve a lower corporate tax rate in their second major legislative priority for the year. President Trump himself bluntly stated this in a budget meeting on February 22.
Smelling imminent demise, Republicans recognized that speed was their only ally. They pushed the legislation forward without real opportunity for debate or amendment, often pressing for votes without final analysis from the Congressional Budget Office, the long-trusted arbiter of the cost and coverage impacts of proposed legislation.
In late March, Republicans made a risky bet. With pressure from the President, they determined that only an imminent vote would push enough of those on the fence to support the bill. That turned out to be a fatal misjudgment. On March 24, Speaker Ryan bluntly, even humbly, acknowledged defeat and pulled the bill from the House floor.
Turns out, though, that may have only been the first chapter. Even as Mr. Ryan uttered his last words at the podium that day, a strong sense of buyer's (or in this case seller's) remorse began percolating among some who had opposed the bill. A key member of the conservative House Freedom Caucus in particular, Congressman Mark Meadows, began direct talks with the White House to modify it to gain his faction's support.
After finding a willing moderate partner, Representative Tom MacArthur, negotiations led to an amendment that was circulated this past Wednesday. Shortly thereafter, the Freedom Caucus endorsed the measure.
The problem is that the Meadows-MacArthur amendment, which allows states to opt out completely of core Obamacare protections, such as those for people with preexisting conditions, likely only weakens the support of many Republicans, not just moderates. Several, it is clear, regret signaling support for the broader Obamacare repeal bill and are hungry for an excuse to pivot.
As for the Senate, let's be clear: this bill is going nowhere. If any repeal-ish bill can coalesce 50 votes in the upper chamber, which is doubtful, it will look completely different from what the House is considering, and will take months to draft.
What this new gasp for breath in the AHCA saga really tells us is that it may never be feasible for Republicans to give up the ghost on repealing Obamacare. No matter what the political fallout and real-life consequences, they think failing to deliver on their promise is worse.
They are victims of their own merciless and highly effective campaign to persuade the public that Obamacare is essentially an incarnation of Lucifer in legislative form. Utterly ignoring its actual contents, they successfully convinced a majority of Americans to associate the law with their deepest fears about government control, health risks, and class warfare. Ubiquity of the phrase "death panel" is the only evidence I need to cite here.
But, as any good salesman knows, the threat of having something taken away can quickly bring the benefits of that thing into focus. Clearly, that is what has happened with Obamacare.
Turns out, people don't want their health care coverage taken away. They believe passionately that those living with cancer shouldn't also struggle to get care. They think it's ridiculous for women to pay more because they carry babies to term.
These are the facts of Obamacare and Obamacare repeal. Having ignored them for so long, Republicans have no choice but to face them head on now. That means investigating the content of the ACA and considering what the facts suggest is working and what needs improvement or repeal. Democrats would welcome this discussion and I’m sure several Republicans, at this point, would too.
Billy Wynne, J.D., is Managing Partner of TRP Health Policy, a Washington-based government affairs and consulting firm that provides comprehensive analysis and strategic advice to hospitals, health systems, manufacturers, and other stakeholders across the healthcare sector. Formerly, he was Health Policy Counsel to the Senate Finance Committee. He received his B.A. from Dartmouth College and his J.D. from the University of Virginia School of Law.