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The BCRA is dead, but Obamacare repeal is still alive

Conservative defections can’t really kill repeal.

Sens. Mike Lee (R-UT) and Jerry Moran (R-KS) said they will join Rand Paul (R-KY) and Susan Collins (R-ME) in opposing the motion to proceed on Mitch McConnell’s Obamacare repeal bill.

That means that the Better Care Reconciliation Act (BCRA) is dead. But the cause of Obamacare repeal is very much still alive. And the cause of preserving its coverage gains — and the welfare of the millions of people who gained insurance thanks to the Affordable Care Act — has now entered a new and dangerous phase.

The problem, fundamentally, for people who care about health insurance coverage is that of the four Republican defectors, only one — Collins — objects to the bill on the grounds that it doesn’t cover enough people.

The other three are complaining, fundamentally, that the bill isn’t “real” Obamacare repeal or doesn’t go far enough. For people’s coverage to be safe, something else has to happen. One or two or three or more of the Republican members who’ve raised concerns about coverage losses need to join Collins in squarely promising to vote against a bill that causes massive coverage losses.

Then they could either leave the ACA in place or start working with moderate Democrats on bipartisan revisions to the bill that would be aimed at improving American health care rather than rolling back insurance coverage. Until then, the Affordable Care Act is very much under threat.

The suspiciously undecided moderates

The real fate of American health care lies with five Republicans — Dean Heller (R-NV), Shelley Moore Capito (R-WV), Rob Portman (R-OH), John Hoeven (R-ND), and Lisa Murkowski (R-AK) — whose behavior since McConnell rolled out BCRA 2.0 has been strange.

These five all clearly and unambiguously stated that the Medicaid cuts in BCRA 1.0 were too severe. But then McConnell went back to the drawing board and came up with a new piece of legislation that made no changes whatsoever to the Medicaid provision. At that point, you would expect everyone who called the Medicaid provision a deal killer to say no to the new bill. And that is, in fact, what Collins did. But the other five have all proclaimed themselves undecided and have made themselves scarce.

With the bill now dead again due to objections from the right, the moderates will probably come out of the woodwork once more and announce that they oppose it too. But the pattern we saw in the House was that once the Freedom Caucus was fully on board with the leadership’s plans, moderates lacked the backbone to actually kill the bill. At the time, House moderates expressed confidence that the Senate process would improve the bill’s coverage provision, but it in fact did no such thing. And now the Senate moderates are, themselves, showing a distinct lack of backbone.

Conservative objections seem like tactical posturing

While conservatives of course have bona fide objections to the BCRA’s vision of the health care system, fundamentally the idea of blocking this law for right-wing reasons makes relatively little sense.

The BCRA cuts taxes, cuts regulation, cuts spending, and cuts the deficit. It may not go as far on some of those items as conservatives would like, but it’s clearly a conservative bill. The big problems with it are that precisely because it cuts taxes, cuts regulation, cuts spending, and cuts the deficit, it will leave millions of Americans without insurance and millions more with skimpier plans and higher deductibles. But that, again, simply goes to show that at the end of the day, this is a profoundly conservative bill that it would be perverse for conservatives to kill.

One possible exception to that is Paul, whose home state of Kentucky is very low-income and embraced the ACA’s Medicaid expansion — meaning Obamacare repeal would, in a concrete sense, be an economic catastrophe for his constituents. From the beginning, many have suspected Paul of playing what David Frum labeled a “denounce and preserve” strategy of offering fake conservative objections rather than admitting that Obamacare is good for Kentucky.

But the other conservatives seem more like they’re angling for a better legislative deal — perhaps a more rapid phase-in of Medicaid cuts or steeper tax cuts — rather than raising fundamental objections.

A bipartisan deal could fulfill Trump’s pledges

The thing that would really kill Obamacare repeal — and preserve its insurance coverage gains — is what McConnell has warned his fellow Republicans against: bipartisanship.

On the stump in 2016, Donald Trump told the American people that he would replace the ACA with something that protected Medicaid and offered patients better coverage with lower premiums and deductibles. And while he was more explicit than other GOP leaders in promising to deliver those things, many Republicans took advantage of Obamacare’s relatively high premiums and deductibles to suggest to voters that they favored making insurance cheaper and more robust.

Mostly they were lying. And certainly Trump was lying.

But this was a smart thing to lie about precisely because that’s exactly what voters want from Obamacare repeal. Not draconian Medicaid cuts or for tens of millions of people to lose their insurance, but for premiums and deductibles to fall so that coverage expands and becomes more affordable.

This would be a very achievable goal if a dozen or so Republicans decided they wanted to work with Democrats to make it happen. A stronger mandate, guaranteed cost-sharing reduction money, and a few simple tweaks like bringing back “risk corridors” and expanding reinsurance funding would set off a virtuous circle. Plans would become slightly cheaper, and going uninsured would become slightly more expensive, pushing healthier people at the margin into joining the exchanges. That, in turn, would lower average premiums and push even more healthy people into joining the exchanges, which would further lower costs — lather, rinse, repeat. The result wouldn’t be a health care utopia, but it would be an improvement over the status quo, which is what people want.

But until work starts on a bipartisan deal, it’s dangerous to assume that repeal is dead. Relying on conservatives to kill a fundamentally conservative bill is inherently risky, and if the perception that repeal is dead demobilizes opponents, then the odds of more moderate Republicans doing anything only fall. Obamacare repeal looked dead in the House at one point, but the very perception that it was dead turned out to give it new life. The only people who can really kill repeal are so-called moderates — who'd have to say no to coverage losses and yes to bipartisanship.

So far, it hasn’t happened.

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