Trumpcare seems dead — or at least in a state of flux on its way to a doomed vote. Caught between conservatives who want a more thoroughgoing repeal of the Affordable Care Act than Mitch McConnell’s legislative blueprint provides and nervous moderates who want to see fewer people lose health insurance, at the moment it appears there is simply no path to get the bill to 50 votes.
The Senate is debating at least four pieces of legislation. Concessions to the right will make it harder to gain votes in the center, while concessions to the center will make it harder to gain votes on the right. While action continues, it’s nothing more than a death rattle. Nobody quite wants to admit that the repeal drive is dead, and every Republican would sort of prefer to make some other Republican take responsibility for it, but fundamentally the bill is dead.
Don’t believe it.
Paul Ryan and the House GOP leadership appeared to be in this exact position a few months ago. But then Republican leaders worked a little magic with the House Freedom Caucus and got all the conservatives on board. Then, even though the bill had become even more extreme, a critical mass of moderates decided they didn’t want to be the ones who killed Obamacare repeal.
Most of all, members of Ryan’s caucus didn’t enjoy looking like failures. And though the moderate members had their doubts about the original bill that weren’t really assuaged by the second bill — they convinced themselves, instead, that the Senate would fix it — they never took any action that would let them claim a win.
Now that the action has moved to the Senate, that’s the way to know when Trumpcare is really dead. Do three or four (or more) Republicans decide to cross party lines and start working with Democrats on a bipartisan bill? If they do, Trumpcare is done. But until they do, it’ll be a zombie that stalks the land and a danger to millions of people who might lose their insurance.
The suspicious Senate 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 all laid low.
Once the bill was dead due to objections from the right, the moderates came out of the woodwork and announced their opposition. 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.
The Senate moderates have the power, right now, to band together and kill the bill by fundamentally rejecting the idea of massive insurance coverage losses. They could cross the aisle and work with Democrats on fixes to stabilize the exchanges. But they keep rather pointedly not doing that.
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.