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Obamacare repeal is stuck because too many Republicans like Obamacare

Charging sick people higher premiums has become unacceptable to a growing group of GOP legislators.

Anti-Trump Activists March To Trump Tower In New York Photo by Kevin Hagen/Getty Images

Rep. Fred Upton (R-MI) came out Tuesday morning against the Republican health care bill. That was big news — Upton used to chair Energy and Commerce, one of the most powerful House committees — and another blow to a party struggling to shore up support for the American Health Care Act.

But the fact that Upton opposes the bill is less important for the GOP’s health care effort than why he said he opposes it. Speaking to a local radio station, Upton identified the reason Republicans are unlikely to move any health reform package through Congress.

It happens right here, in the two sentences I’ve bolded:

The way that it is structured right now, there is an amendment that is in essence part of this bill that now allows the governors to waive pre-existing illnesses as part of essential benefits. The Freedom Caucus insisted on this provision, they’ve added it in the rules committee. As you may know I’m not at all comfortable with removing that protection. I’ve supported the practice of not allowing pre-existing illnesses to be discriminated against from the very get-go.

We know the Senate would never accept this provision. There is some thought about, let’s just send it to the Senate, let them fix it, and send it on to the president. I sat down with a number of Freedom Caucus folks yesterday and they’re not willing to budge, at least at this point. I can tell you there are a number of Republicans who are saying this isn’t going to fly.

We’ve talked about the protection for those with pre-existing illness for last number of years. We’re not going to budge either. How it plays out, I don’t know, but there are not the votes as of this morning to move this vote forward.

Republicans’ rallying cry, for years now, has been four words: “repeal and replace Obamacare.” But we’ve seen that evolve since the party took control of Washington. Legislators are divided into two camps: repeal or replace.

One side wants to wipe Obamacare off the books. The other side wants to keep the law’s key insurance reforms. In particular, that side has vociferously defended Obamacare’s ban on preexisting conditions.

Neither side, as Upton says, is willing to budge. Until that changes, Republican health reform efforts look dead in the water.

Obamacare made the individual market more equitable. Some Republican legislators like that.

The Affordable Care Act did many things to reform the individual market. It ended discrimination based on preexisting conditions, ended lifetime limits on health insurance, and required insurers to cover a core set of health benefits.

All of these changes were motivated by the same principle: It should be easier for sick people to get affordable coverage in the individual market. This had trade-offs. It required healthy people to pay higher premiums to cover the higher medical bills of sick enrollees.

Bringing unhealthy people into the market is difficult “because it requires the healthy people who had a sweet deal in the past to pay higher rates,” says former Health and Human Services Secretary Kathleen Sebelius. “There is no question that some people’s rates went up, but the old market didn’t work very well for the majority of people who needed coverage.”

Sebelius still believes Democrats made the right call. It was worth it, she believes, to ask healthy people to pay more so sick people could gain coverage, too.

What we’re seeing in the Republican Party right now is a divide between legislators who agree with that principle and those who don’t. The Freedom Caucus has made it clear that it does not agree with this view. Its members are okay with different trade-offs. Namely, they are okay with sicker people paying more (or not getting coverage at all) to allow healthy people to get cheaper coverage. This would be similar to the old individual market, before the Affordable Care Act passed.

But increasingly, we’re learning that there is a sizable number of Republican legislators who agree with the Obamacare’s core principle — who say it is bad to have an insurance market where people who are sick, often at no fault of their own, can’t get affordable health insurance coverage.

This is what Upton said in his remarks today. It’s what Rep. Billy Long of Missouri, a previously staunch Trump ally, said when he came out against the bill yesterday.

“I have always stated that one of the few good things about ObamaCare is that people with pre-existing conditions would be covered,” Long said in a statement. “The MacArthur amendment strips away any guarantee that pre-existing conditions would be covered and affordable.”

This is what House Deputy Whip Patrick McHenry said a few weeks ago, too.

“There are a lot of provisions that I've campaigned on for four election cycles that are part of the law now that I want to preserve,” he told Bloomberg. “So if you look at a cross section of the conference, they have similar positions about similar provisions — preexisting conditions, guarantee issue and medical underwriting are components of that.”

As former Republican Senate aide Chris Jacobs presciently described the situation in February, it appears legislators have split into two camps: “the repealers” and the “replacers.” Each faction took the part of the Republican slogan they liked, and clung to it.

There is little space for compromise between these two positions. Either the Republican replacement plan will let insurers charge sick people higher prices, or it won’t.

Statements like these have badly damaged Republican repeal efforts, not just because legislators have opposed the bill. Rather, their statements make clear the stark choice that Republicans face with this bill — either to allow insurers to charge higher premiums or not.

Where does Trump stand on health care? Who knows!

Making this debate more confusing, Trump has never clarified which side of the debate he stands on. Many of his statements suggest he is in the “replacer” camp. He constantly talks about the importance of protecting Americans with preexisting conditions while also voicing support for a bill that doesn’t do that.

“Preexisting conditions are in the bill,” he told CBS Sunday. “I just watched another network than yours, and they were saying, ‘Preexisting is not covered.’ Preexisting conditions are in the bill. And I mandate it. I said, ‘Has to be.’”

Is Trump with the Freedom Caucus? Is he on Upton’s side? It’s hard to know. The best evidence suggests he’s on his own side: He wants a bill to pass, and doesn’t care much about what is in it. As he reportedly told legislators in March, "Forget about the little shit. Let's focus on the big picture here."

Right now, Trump isn’t bridging the divide between Republicans. He’s exacerbating it. He is sending signals to both sides suggesting he supports their cause, while remaining coy about his actual policy positions. Legislators are left to guess which side the president is on — and, in the meantime, hold out in their separate camps.

Obamacare changed the goal posts on health care in America

What is happening in the Republican Party now seems to be evidence of something that Vox’s Ezra Klein wrote about a few months ago: The Affordable Care Act has shifted health policy consensus in the United States to the left.

Before the Affordable Care Act, it was a major policy undertaking to ban preexisting conditions. Now that regulation is the status quo. A year ago, I was a guest speaker at a class of undergraduate students, where I gave a presentation on the health care law. One of them stopped me when I used the term preexisting condition. He’d never heard it before, and was surprised to hear that insurers used to reject sick people from coverage.

“The debate on health care has moved from whether it should be the government’s responsibility to insure young, able-bodied people to how the government should insure young, able-bodied people, and how comprehensive the insurance should be,” Klein wrote in February.

This helps explain how a longtime Republican legislator like Upton can go from criticizing Obamacare’s insurance reforms in 2013 to supporting them in 2017. It explains why Republicans’ efforts to repeal Obamacare are struggling: Too many members of their party have been sold on the law’s key principles.