The failure of the House to pass the American Health Care Act (AHCA), leaving the Affordable Care Act unrepealed, is of course great news, both for people who need health care and for the cause of responsible, responsive public policy. That 24 million people will have health insurance who would not have it if the AHCA had passed is reason enough to celebrate. The Affordable Care Act needs continual refining and improvement, which it probably won’t get, but the fundamental framework of the ACA survives, and eventually we’ll return to the task of fixing and expanding it.
Equally important, the failure of the AHCA demonstrated that citizens, mobilized, can still be heard, even in a political process dominated by money and in which elected officials have at times seemed desperate to cut themselves off from their own constituents. And it is notable that President Trump has been exposed as a lousy negotiator, whose clumsy threats and demands held no power, even over representatives in districts Trump won by the highest of his margins. The illusion that dissenters would be deterred by the threat of primary challenges driven by Trump loyalty has been quickly shattered. The rest of Trump and Paul Ryan’s agenda, of which ACA repeal was supposed to be the first and easiest item, has fallen further out of sight.
These are things worthy of celebration, not only because more people will have health care than otherwise, but because they are faint signals that the basic mechanisms of democratic accountability might still be functional.
Yet we should also take a few minutes to be angry, furious even, about the sad last act of this long political showdown, one that consumed, as Senate Majority Leader Mitch McConnell put it this week, “the better part of a decade.”
Consider this: Long before Donald Trump came along, the Republican Party ran four election campaigns — 2010, 2012, 2014, and 2016 — on the promise to rid the country of the hated and oppressive Affordable Care Act, or “Obamacare” as they alone called it until 2011, when President Obama unwisely embraced the epithet. In three of those four elections, they captured another arm of government, all on the promise of ACA repeal: the House in 2010, the Senate in 2014, and the White House in 2016.
Every time you read about how many House and Senate seats, how many statehouses, how many thousands of seats in state legislatures turned Republican since 2008, think about how many of them swung on the backlash against the Affordable Care Act. Not all of them, to be sure, but even at the state level, Medicaid expansion and whether to form a state exchange were central questions in a great many election fights, always as symbols of oppressive big government. And there wasn’t one House or Senate race in which some aspect of “Obamacare” didn’t play a major role.
Yet in all this time, the Republican Party never fully articulated an alternative, beyond phrases like “patient-centered” or “market-based.” (The ACA is, in fact, a market-based system.) It’s now seven and a half years since Eric Cantor, then the Republican whip and a rising star, promised a full alternative to the ACA “within a few weeks.” The various repeals Republicans passed were rough sketches, doomed to failure in the Senate or veto, purely symbolic votes.
And then, when the moment came, when Republicans finally had full control of government, it took barely two months for them to admit they hadn’t really thought it through.
It hadn’t really occurred to them that repealing the individual mandate and cutting the subsidies would result in many millions uninsured or raise premiums massively on people in their 50s and 60s. It didn’t seem to have occurred to them that the demands of the House Freedom Caucus members, the most unflinching ideologues to achieve near-total repeal, the desire by less conservative members to keep at least the basic structure of benefits, and the president’s promise to improve every single thing could not be easily accommodated. They hadn’t considered the possibility, indeed the likelihood, that as unpopular as the ACA remained, their own alternative would be even more unpopular, not least because change alone is terrifying to people when they think about health care.
Long before Barack Obama took office, many of the most basic policy choices had been hashed out among health reform advocates, interest groups, and experts left and center, meeting in various configurations. That’s why the basic framework of exchanges, insurance regulations, and subsidies, with the public option and individual mandate as optional features, was central to almost every 2008 Democratic candidate’s proposal (Rep. Dennis Kucinich remained a single-payer supporter, and candidate Obama dodged the individual mandate) and continued to define the basic structure all the way through the long path to enactment.
Everyone involved understood the basic choices, and if they didn’t always like provisions like the individual mandate, they understood that the parts they did like, such as the requirement to cover preexisting conditions, depended on the others.
Despite years to prepare, repeal supporters did none of that work. Options were suddenly discovered and thrown into the bill at the last minute, with unpredictable costs and trade-offs. And while President Trump’s ineptitude, coupled with his vacuous promise to provide better, cheaper health plans that would cover everyone, complicated matters, it’s likely that even if Ted Cruz or Marco Rubio occupied the White House, the result would be the same.
That’s because long before they failed to develop an alternative to the ACA, it had become apparent that Republicans lacked a coherent argument about what was wrong with the law. In the early years, they talked about the individual mandate a lot, as a potent symbol of state control over the individual, but after the Supreme Court upheld the mandate, they lost interest in that argument. They denounced it as a “one size fits all” solution, but that’s actually unspecific and deceptive — what “size” would work better? More recently, and with impressive talking point discipline, they decried it in technocratic terms — it wasn’t working because premiums had soared in some states, and there was only one insurer in many counties. Those are real issues, but they are a long way from treating the ACA as the EZ-Pass Lane on the Road to Serfdom.
And mostly, to the very last moment and even when it had crossed the line to absurdity, they denounced the legislative process of 2009 and 2010. They repeated endlessly then-Speaker Nancy Pelosi’s line: “We have to pass the bill to find out what’s in it.” They pretended the months of hearings, markups, open floor debates, and careful pauses while waiting for the Congressional Budget Office to score the latest changes had never happened. Even as they pushed their own bill toward the floor without hearings or amendments, they claimed to be operating an open process in contrast to Obama and Pelosi, when the opposite was true.
The usual political advice would hold that an argument about process is rarely persuasive, because people care only about the substance of what they get from government, not how the legislative process got there. Much successful, popular legislation has an ugly creation story, but no one cares.
In the case of the Affordable Care Act, people did care. The “Cornhusker Kickback” and other transactions that won over the last stragglers were remarkably well-known, and the fact the bill passed along party lines (with the forgotten exception of one indispensable vote by former Sen. Olympia Snowe of Maine, in the Finance Committee) itself raised questions about its legitimacy.
If the process was illegitimate, the implicit argument went, then it was easy to believe it was less than optimal. Maybe plans could be much cheaper, deductibles lower, or enrollment hassles fewer. If there were problems in our staggeringly complex public-private health insurance system, and there always are, they could be attributed to the corrupt, closed process by which the ACA was passed.
But the failure of repeal shows that the Affordable Care Act process, while it didn’t lead to a perfect result, didn’t leave some better option on the table. It was about as good as Congress could do, within the lines of a private system of exchanges and subsidies to expand coverage.
If the goal of the campaign against the Affordable Care Act was to repeal the Affordable Care Act and leave millions without health care, it failed, thankfully. But if the goal was to win election after election, and virtually wipe out the Democratic Party across much of the country, while never actually engaging with the tough questions of health care, then it succeeded beautifully. And that success lives on. It is really one of the longest, most coordinated political deceptions in American history, and one in which Trump is only a minor player.
Other crises and issues are likely to emerge between now and the 2018 midterm elections. So it’s entirely possible that Republicans will pay no political price attributable to today’s failure 19 months from now. That is to say, Democrats paid a staggering, existential price for finally succeeding in delivering health insurance to almost everyone. And Republicans will pay none for eight years of pretending they had a better, cheaper, painless way to reach the same goal, only to reveal at the end that they had nothing, not even a Laffer curve drawn on a napkin.
I’m still angry about that.