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Republicans can’t repeal Obamacare because they can’t replace it

“I’ve seen how we’ve struggled with this.”

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Seven years ago, just as the Affordable Care Act was becoming law, senior Republicans decided they would not campaign only to repeal it. No, they would vow to repeal the law and replace it with a more conservative health policy.

They didn’t know it at the time, but they were painting themselves into a corner.

The “repeal and replace” message was a concession that simply promising to return to the days before Obamacare, especially once millions of Americans were covered through the law, was politically unpalatable. But it also committed them to coming up with a plan of their own.

Then the GOP spent the next seven years running a scorched-earth campaign against Obamacare, turning a blind eye to the deep divisions within their own party on the “replace” portion of the pledge.

Last week, the consequences became clear as Republicans have so far failed to coalesce around a bill meant to replace the health care law.

“We’ve been struggling for months to try to find a replacement vehicle,” Sen. Shelley Moore Capito (R-WV), a critical swing vote who opposes repeal only and the current repeal-and-replace plan, said late last week in a local radio interview.

Repeal and delay was off the table for her, even though she voted for it just two years ago.

“I don’t think that it’s a responsible way to repeal something, have everything fall off a cliff … and have no plan in front of us,” Capito said. “I don’t think the US Congress does too well with deadlines. I don’t think that’s when good policy comes forward.”

But replacement had proven no easier..

“I’ve seen how we’ve struggled with this. I’ve seen the different ideas and panic that sets through with people when they don’t know what they’re going through,” Capito continued. “We’ve been all over the board on this.”

In a few short sentences, the West Virginia senator captured the original sin of the Republican war against Obamacare: They decided they couldn’t repeal it without a replacement. But they never got around to figuring out what the right replacement plan was.

They still haven’t.

In 2010, Republicans decided they’d campaign to “repeal and replace” Obamacare

The highest levels of the GOP concluded as soon as Obamacare was passed that their strategy must be to campaign on repealing and replacing the law.

The New York Times’s Carl Hulse documented the history in January, when it was already becoming clear that Republicans would struggle with the second part of their two-part promise:

In March 2010, on the day before President Obama was to sign the Affordable Care Act into law, a group of senior Republican aides huddled in Senator Mitch McConnell’s Capitol suite to try to come up with a catchy slogan to use against it.

Many conservatives were simply advocating a vow to repeal the new law, but Republican strategists worried that pressing for repeal without an alternative could backfire. So they batted around a few ideas before Josh Holmes, then a top communications adviser to Mr. McConnell, tossed out the nicely alliterative phrase “repeal and replace.” That seemed to do the job, with its promise to get rid of the new law detested by Republicans while suggesting that something better would follow.

It became the pillar of every Republican congressional campaign in 2010, 2012, 2014, and 2016. Mitt Romney promised to repeal and replace Obamacare, standing in front of huge banners with the slogan. President Donald Trump pledged to do the same again and again on the campaign trail.

Even today, amid all the turmoil about the actual Republican plan to accomplish it, conservative voters overwhelmingly prefer “repeal and replace” to “keep and fix”: 76 percent, according to an April poll from the Washington Post and ABC News.

One Republican health care lobbyist described the party’s blind faith in repeal as the inverse of the Democratic belief that people would warm to Obamacare once they found out what’s in it: “We repealed it and therefore you must love it,” the lobbyist said. “What it actually does is irrelevant.”

Republicans have had ample time to craft a viable replacement plan, and several opportunities when doing so made sense. There was the 2012 Supreme Court case that risked invalidating the entire law, the presidential campaign that same year, and the 2013 Supreme Court that would have rendered the law unworkable in most of the country.

Yet after all that time, Republicans have fumbled. “Regretfully, it is apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” McConnell said in a statement last week, as he sought to set up a vote on a clean repeal bill.

It was a remarkable concession from the man who helped birth the repeal-and-replace message.

Republicans can’t agree on a replacement plan, and the plan they do have is deeply unpopular

But McConnell was left with no other options, though his caucus has since decided to make one last mad dash toward a repeal-and-replace compromise.

Moderates were wary of ending Obamacare’s Medicaid expansion, rolling back protections for people with preexisting conditions and voting for a plan to result in 22 million fewer Americans having health insurance — not to mention a major overhaul of Medicaid that really had nothing to do with the 2010 health care law.

Conservatives thought the current plan didn’t do enough to unwind Obamacare’s insurance regulations, their No. 1 culprit for increased premiums; lowering premiums, not covering more people, has been their primary concern.

“Whether we can reconcile the two [sides] and resolve those questions is the outstanding issue,” Sen. John Thune (R-SD), a member of Senate leadership, told reporters last week. “This is going to be very hard.”

So Republicans are still stuck, after seven years.

There is a certain fatalism at work among Republicans in Washington. The health care lobbyist told me that anybody could have seen that we would end up here, given the parameters that Republicans were working under. These were the necessary conditions for any Republican plan to replace Obamacare:

  • Repeal Obamacare’s taxes and add no new taxes
  • Get rid of the law’s Medicaid expansion
  • Cap federal Medicaid spending to save the money lost from repealing taxes
  • Try to pivot as far away from Obamacare, by shrinking the financial assistance for private coverage and rolling back the law’s insurance regulations

The plan Republicans do have checks each of those boxes, more or less.

“We were doomed to fail to this moment,” the lobbyist said. “We are where we are because that’s all we could do.”

That specific plan, the culmination of seven years of rhetoric, is devastatingly unpopular. A recent Fox News poll found that 52 percent of Americans approved of Obamacare, among its highest marks, while only 27 percent supported the GOP’s bill.

Why has it all gone wrong? There is a truism that it’s easy to give Americans benefits and incredibly difficult to take them away. That has borne out, as the health care law surges in popularity at the same time it faces its most existential threat.

But there is another truth that Republicans never grappled with in seven years of promising to repeal Obamacare: The law is, in many ways, fundamentally conservative and market-reliant. Yes, it regulates insurance more heavily than before. But it depends on private plans to cover millions of Americans. It expanded Medicaid, but even that, in practice, has been outsourced to the private sector in some states.

“I’ve come to an answer that will be hard for many conservatives to swallow,” Craig Garthwaite, a Northwestern University professor and self-identified Republican wrote in the Washington Post this month. “Passing an Obamacare replacement is difficult because the existing system is fundamentally a collection of moderately conservative policies.”

Given the chance to do as they promised, Republicans found they had nowhere to go.