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Why Obamacare repeal failed

And why it could still come back.

McConnell Trump Ryan The Washington Post / Getty Images

Republicans’ seven-year quest to repeal Obamacare ground to a halt at 1:30 am on Friday when Sen. John McCain (R-AZ) approached the podium in the Senate chamber, raised his arm, and gave the clerk a thumbs down.

Obamacare repeal was, for the foreseeable future, dead.

The simplest explanation of why Obamacare repeal failed is that McCain’s vote — coupled with longstanding opposition from Sens. Lisa Murkowski (R-AK) and Susan Collins (R-ME) — meant that the Health Care Freedom Act could not move through the chamber.

But understanding why Republicans are so stuck on Obamacare repeal requires digging a bit deeper. How does a party campaign on a very specific policy and then, after gaining control of all levers of government, struggle to deliver on it?

One part of the answer is political: Too many Republican legislators actually like certain parts of the health care law — and their constituents like them too. No legislative strategy can skirt around the fact that millions now rely on the health care law for coverage, and do not want to lose their benefits.

Republicans also had a big policy problem: They are stuck because while they promised to repeal and replace the health care law, they never came to agreement on what the replacement would look like, what goals it would achieve, or what problems in Obamacare it would fix.

Meanwhile, the Affordable Care Act is working. Not working perfectly, by any means, but working well enough that enrollees value their coverage. Any of the Republican plans so far, on the other hand, would leave millions without coverage, raising deductibles for most and premiums for many.

We are two reporters who have spent six months covering the repeal effort here in Washington and out in the states. Republicans’ struggles to pass a bill have offered plenty of lessons in how both Congress and the Affordable Care Act work. They’re lessons important to Republicans who want to repeal the law — and Democrats who want to save it.

Lesson 1: replacing Obamacare will remain a struggle without a clear replacement plan — or goal

On one of his last days in office, President Obama, in an interview with Vox, issued the Republican Party a clear challenge. “Now is the time when Republicans have to go ahead and show their cards,” he said. “If in fact they have a program that would genuinely work better, and they want to call it whatever they want — they can call it Trumpcare or McConnellcare or Ryancare — if it actually works, I will be the first one to say, ‘Great.’”

“I suspect, Obama continued, “that will not happen.”

So far, the former president’s prediction has proven right. Republicans have struggled over the past six months because they never came up with a clear replacement plan that the public actually wanted.

The day before Obamacare was signed, Republicans decided they would not campaign only to repeal the new health care law. They would instead vow to repeal and replace it with a more conservative health policy.

The “repeal and replace” message was a concession that simply promising to return to the days before Obamacare was unrealistic. But it also committed them to coming up with a plan of their own — and that part never happened.

After Republicans swept the House, the Senate, and, finally, the White House, they still had no clear replacement plan. The GOP had spent seven years running a scorched-earth campaign against Obamacare, while turning a blind eye to the deep divisions within their own party on the “replace” part of their pledge.

The consequences of that negligence became clear to Republicans themselves as they took on the hard work of coming up with that replacement. The party set a handful of necessary conditions for an Obamacare replacement plan:

  • 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 as possible, by shrinking the financial assistance for private coverage and rolling back the law’s insurance regulations

The most ambitious plans Republicans had come up with did check those boxes, more or less. But those plans were overwhelmingly unpopular and divided Republicans against each other.

The repeal fight has laid clear a truth that Republicans had refused to accept 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 last month. “Passing an Obamacare replacement is difficult because the existing system is fundamentally a collection of moderately conservative policies.”

The Republican plans were also often at odds with the promises they made. Take, for example, the issue of deductibles. Republican legislators constantly argued deductibles under Obamacare were too high, with good reason: Polls of Affordable Care Act enrollees find this is the part of their plans they are least satisfied with.

“The deductibles are so high that it’s really not worth much to them,” Senate Majority Leader Mitch McConnell said in a January interview.

But each plan Republicans introduced would raise deductibles, not lower them, by making the plans in the individual market skimpier rather than more robust.

Over the last week of the Senate health care debate, Republicans’ dreams of Obamacare repeal shrank dramatically. They had walked back from overhauling much of the law, ending Medicaid expansion, and fundamentally changing Medicaid forever to simply repealing the individual mandate, the law’s least popular provision, and a few other pieces.

Even that so-called “skinny” bill could not secure the votes. Their own members panned it in the harshest possible terms.

“The skinny bill as policy is a disaster,” Sen. Lindsey Graham (R-SC) told reporters shortly before the plan failed on the floor.

Lesson 2: repealing Obamacare is hard because taking away benefits is hard

Paul Pierson is a political scientist at the University of California Berkeley who has written volumes on the challenge of rolling back welfare programs.

“People who are receiving benefits, they’re going to react pretty strongly to that being taken away from them,” Pierson told Vox’s Dylan Matthews earlier this year. “Each taxpayer is paying for a lot of stuff and cares a little bit about each thing, but the person who’s receiving the benefits is going to care enormously about that.”

The past six months were a real-world test of Pierson’s thesis: Would his findings hold on the Affordable Care Act — or would he have to rethink how safety net programs function in a hyperpartisan era?

So far, Pierson’s theories have held. In the Senate, many GOP lawmakers did not actually want to roll back all of Obamacare’s expanded coverage. Over three days, enough Senate Republicans voted against it to kill three different iterations of repeal.

Two of them opposed all three: Sens. Collins and Murkowski. They had made clear for weeks that simply undoing what Obamacare had accomplished — coverage gains, expanded Medicaid, protections for people with preexisting conditions — was unacceptable. When the Senate proposed these changes, it was a nonstarter for the pair.

“I want greater access and lower costs. So far, I'm not seeing that happen,” Murkowski told Vox in mid-June. Collins made her position equally plain: "I cannot support a bill that is going to result in tens of millions of people losing their health insurance,” she said in June.

The math on each of the Senate GOP plans was clear. Repeal and replace: 22 million more uninsured. Repeal only: 32 million. “Skinny” repeal: 16 million.

The striking coverage losses made other senators flinch. Sen. Dean Heller (R-NV) also voted against repeal and replace and clean repeal after holding a press conference last month with his state’s Republican governor, saying that the gains made after Nevada expanded Medicaid shouldn’t be reversed.

“We can’t let fall behind the progress we’ve made in Nevada,” Heller said.

Likewise, West Virginia Sen. Shelley Moore Capito said she couldn’t support the repeal-only legislation: “I did not come to Washington to hurt people,” she said.

Eventually, Heller and Capito did vote to repeal the individual mandate. But Collins and Murkowski held firm over the two-month debate. On the night that it became clear the Senate’s last-ditch plan would fail, Collins looked delighted. She huddled with Murkowski and McCain, who would soon be the decisive third vote to kill the legislation, all laughs and smiles.

Murkowski, on the other hand, endured one final lobbying campaign from her peers. Already subjected to outright threats from the Trump administration for refusing to back the health care bill, she was surrounded during the climatic vote on the Senate floor by a half-dozen of her Republican colleagues, a pink sweater in a sea of dark suits.

But Murkowski was unfazed. When her name was called on the final roll call, she quickly if quietly said, “No.”

Alaska struggles with the highest health care costs in the country. But it expanded Medicaid to cover its poorest residents and saw tens of thousands of people sign up for private coverage. The consequences of repealing the law were, in the end, too much for Murkowski to take.

Lesson 3: Obamacare is hard to repeal because Obamacare is working

Republican senators talk about the Affordable Care Act as a massive burden its enrollees shoulder, a world where Americans are forced to purchase a product that does them no good.

I, Sarah, have interviewed dozens of Obamacare enrollees, and most do not see the law this way. They certainly have their gripes — the deductibles are too high, the choice of doctors too limited — but at the end of the day, they prefer the system now to the one that existed before the health law and the one Republican plans would create.

And this isn’t just my reporting. The Kaiser Family Foundation recently interviewed 786 Affordable Care Act enrollees. They found that 80 percent of individual market enrollees rated their coverage as “excellent, very good, or good.” Only 5 percent said their coverage was “poor.”

The health care law is, for the most part, working, with isolated trouble spots. There are 11 million people who get coverage through the insurance marketplace and even more enrolled under the Medicaid expansion. It is true there are 19 counties with zero health plans signed up to sell coverage in 2018 — but it’s also true that there are 932 counties with three or more plans.

Insurance plans appear to have finally turned the corner and begun to make a profit on the marketplace. Analysts were initially projecting small rate increases in 2018, although that might not bear out due to specific policy choices made by the Trump administration.

Obamacare is not perfect, but its enrollees do seem to prefer it to any alternative the Republicans have offered. This includes Stacie Boschma, a 41-year-old freelance copywriter in Atlanta who buys coverage on the marketplace. She spends about $400 a month for a plan with a deductible of $5,000. Plans in her area have gotten expensive enough that she and her wife can’t afford a policy for both of them. Instead, only Stacie gets coverage (because she has diabetes and needs coverage for her insulin), and her wife, Alicia Mintz, goes uncovered.

Boschma would definitely prefer a health care system where she and Alicia could purchase afford insurance. She’d love a plan with a lower deductible, too.

“I felt like the law worked really well a few years ago, when I could get a plan for $175 [monthly premium],” Boschma said.

But here’s the rub: The Republican plans did not deliver that type of future. They took the things that Obamacare enrollees don’t like about the program and made them worse.

In Boschma’s case, she worries about even higher deductibles or the possibility of insurers rejecting her if preexisting conditions come back (as they would under an proposal from Texas Sen. Ted Cruz and the House-passed American Health Care Act). She can see a future where neither she nor her wife can buy a plan.

Even the Obamacare enrollees who supported Trump and Republican legislators didn’t think much of a plan that would leave them without coverage. Those I interviewed in southeastern Kentucky in December and again in May expected their coverage would get worse under their representatives’ plan.

“From what I’ve read on it, it’s not going to be good for anybody,” said Chuck Hoskins, a 62-year-old retired coal miner who has coverage through a highly subsidized Affordable Care Act plan.

Obamacare would be easy to repeal if it were the burden Republican legislators describe it as. But it isn’t, and that has made rolling back the law an especially vexing task.

Lesson 4: passing a bill in secret is a tempting strategy — but doesn’t actually work

House Republicans at least attempted a facsimile of regular order, sending their legislation through a few rushed committee hearings. The Senate didn’t even bother.

The original Senate repeal-and-replace bill had been negotiated and drafted entirely in secret for two months. No public hearings, no expert testimony. Even as a number of Republican senators expressed discomfort, none of them stopped it.

Adding to the absurdity: Senate leaders had also set their sights even bigger than Obamacare. Their most ambitious proposal would have not only repealed and replaced much of the health care law but also fundamentally overhauled Medicaid. Republicans were pushing to restructure a 50-year-old program that covers more than 70 million Americans without holding a single hearing.

The consequences: more than $700 billion in federal spending cuts, versus current law, and a projected 15 million fewer enrollees.

Collins, for one, was aghast.

“To do that without holding a single hearing on what the implications would be for some of our most vulnerable citizens, for our rural hospitals and our nursing homes, is not an approach that I can endorse,” she said in recent days.

Murkowski, too, bristled at the secretive deliberations and drafting of legislation to overhaul one-sixth of the American economy. To top if off, the Senate’s talks had opened with a 13-person working group, all men, excluding Murkowski and Collins and the other Republican women.

A month into the negotiations and a month before she would help kill the bill, Murkowski vented to me, Dylan, while we paced through the Senate basement, frustrated that she still didn’t know what was in her party’s plan and was unable to answer questions from her constituents.

“I don't know what it is that will actually come forward. This has been part of my frustration. What's the Senate bill going to look like? I don't know,” she said.

There was a rich irony in it, after Republicans slammed Democrats for years for, as they put it, passing Obamacare in the dead of night.

“We're setting ourselves up for the same criticism we waged against our colleagues on the other side,” Murkowski said.

Such parallels were on the mind of a third Republican senator: Arizona’s John McCain.

He wasn’t even supposed to be there. Just weeks before, he had had emergency surgery for a blood clot and then discovered he had brain cancer. He was thought to be out for weeks.

An unexpectedly swift return to the Senate was supposed to be a boon for Senate Republican leaders, and it was — until the last moment.

A few signs had suggested McCain’s turn. Two days before the last Senate vote, even as he voted to open the health care debate on the Senate floor, McCain hinted at what was to come. He gave a floor speech after the vote to open debate, calling for a return to regular order and a spirit of bipartisanship.

“We try to do this by coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them that it's better than nothing,” he said in that floor speech. “That it's better than nothing? Asking us to swallow our doubts and force it past a unified opposition.”

“I don't think that's going to work in the end,” he continued, “and it probably shouldn't.”

He delivered those words at the same time Republican leaders were launching their most audacious attempt yet to circumvent any sense of legislative normalcy.

Realizing that they didn’t have the votes for repeal and replace or repeal only, they cooked up so-called “skinny” repeal — eliminating just Obamacare’s individual mandate and a few other provisions. The bill was unveiled to the public late Thursday night, just two hours before the first vote on it.

Senate leaders were also making a rather puzzling promise: The bill wasn’t actually intended to become law. It was simply a vehicle to enter conference negotiations with the House. In other words, the argument was that senators should pass this shell of a bill and then negotiate to come up with the real plan.

McCain, who had expressed skepticism about the Senate repeal-and-replace bill and voted against repeal only, seemed thoroughly unsatisfied with “skinny” repeal as well. Even tepid assurances from House leaders that they would enter negotiations with the Senate didn’t assuage him.

“I’ve stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict party-line basis without a single Republican vote,” McCain said in a statement after his stunning vote.

“We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people,” he said. “We must do the hard work our citizens expect of us and deserve.”

The floor vote was dramatic. It became clear something was amiss when McCain spoke briefly with the top Senate Democrat, Chuck Schumer, and Schumer seemed elated. A conversation with the No. 2 Republican, John Cornyn, left the Texas senator looking dour.

As Republican leaders held a vote on a Democratic motion open for more than an hour, McCain stood firm. His Arizona colleague, Jeff Flake, sat next to him, but seemed unable to get a word in. McCain gabbed comfortably with Sen. Lindsey Graham (R-SC), his best friend in the Senate.

The showdown was with Vice President Mike Pence, present in the Senate in case he needed to cast a tiebreaker vote to give the “skinny” repeal bill a 51-vote majority. McCain and Pence spoke for nearly 30 minutes, in a conversation that at times seemed friendly but then turned serious. McCain was insistent. Pence huddled with McConnell and left the floor for a time. McCain stepped into a back room, believed to be taking a phone call.

But the Arizona senator was unmoved. When he turned his thumb down, “skinny” repeal — the Republican Party’s last hope, for the time being, to repeal Obamacare — was dead.

Lesson 5: the drive to repeal Obamacare is strong, and often underestimated

Early Friday morning, bleary-eyed reporters couldn’t see the path forward on Obamacare repeal and replace no matter how hard they squinted. The Senate hadn’t just rejected one health care bill — it had rejected four different options, all the repeal bills it had going into this week.

This means Obamacare repeal-and-replace efforts are in a hard place. But it does not mean they are over.

It is true that three Republican senators voted against the skinny plan to repeal Obamacare. It is also true that 49 Republican senators voted for that bill.

There is a strong drive in the Republican Party to deliver on the campaign promise they've made for seven years, and if we've learned anything in this process, it is that this drive cannot be underestimated.

Within moments of the bill's failure Friday morning, the conservative Heritage Action group released a statement arguing that "Repealing and, ultimately, replacing Obamacare will require moderate Republicans to come to the table and follow through on their repeated campaign promises."

House Republicans, meanwhile, continue to hold out hope for a path forward. Vox's Tara Golshan was at the conference's regular Friday meeting this morning, where she spoke with conservative Freedom Caucus Chair Rep. Mark Meadows (R-NC). He was already talking about paving a new path forward, citing a yet-to-be-seen bill from Sens. Graham and Bill Cassidy.

Graham reportedly attended a White House meeting where he pitched his bill. Trump surrogates took to the Sunday morning shows this weekend, making clear that they saw this battle as far from over.

Kellyanne Conway told Fox News that Trump would decide “this week” whether to implode the Affordable Care Act. Health and Human Services Secretary Tom Price seemed to hint that he might consider laxer enforcement of the individual mandate, which he claimed drove up premiums (all available analysis suggests the opposite — the mandate holds premiums down, and does not drive them up).

The Republican Party cannot seem to quit Obamacare repeal. It has stuck with the goal through failed votes, dismal approval ratings for its bills, and vicious town hall meetings this past spring.

The 72 hours after the failed Senate vote suggests that legislators do not see that moment as Obamacare repeal’s death knell. Instead, they view it as one failed battle in a lengthy war — one they do not plan to quit anytime soon.

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