The history of the development of the Republican alternative to Obamacare since the beginning of the health-care debate, in 2009, has been an endless loop of loud promises that a full plan will be announced soon, followed by quiet admissions that it will not. Seventeen days ago, Donald Trump promised a vote to repeal the law “probably some time next week” with a vote for a replacement “very quickly or simultaneously, very shortly thereafter.” At a meeting in Philadelphia yesterday, Trump and his House Republican allies produced no agreement on a plan. If there is a consensus, it is that there will be no replacement plan at all.
Representative Greg Walden, a key leader of the House Republican efforts on health care, tells Julie Rovner, “There’s no single fix. There’s no single plan.” Representative Marsha Blackburn touted bills to limit medical malpractice lawsuits and to allow the sale of state-regulated insurance across state lines. Neither of these proposals would have any significant impact on insurance coverage. If Obamacare is repealed, this would leave the individual-health-insurance market a smoldering crater.
Republicans are portraying the lack of a plan as a philosophical aversion to lengthy legislation. “If you’re waiting for another 2,700-page bill to emerge, you’re going to have to wait until the sun doesn’t come up, because that’s not how we’re going to do it,” says Walden. You may not need 2,700 pages of legislative text. But you can’t blow up the health-care system and replace it with a series of piecemeal measures. Any real plan to provide even crappy coverage — let alone the better, more affordable coverage Trump has repeatedly promised — is going to need to be paid for. Making those trade-offs means figuring out some big-picture strategy for where the money will come from.
The reason health-care reform is done by assembling a big bill with a high page count is that all the stakeholders want to know beforehand whether the final product will be acceptable to them. Hospitals or insurers or doctors or drug makers might be willing to accept provisions that hurt their bottom line if there are other provisions that help them. But they won’t support passing a bill that hurts them on the promise of getting help in a future bill, because they don’t know whether the future bill will pass. Going step by step is a talking point, not a plausible way to actually write laws.
Step-by-step changes could work if they leave the current system in place and alter it incrementally. But if you blow the market up, you need comprehensive changes to rebuild something in its place.
Several Senate Republicans have expressed severe reservations about repealing Obamacare without having a replacement. Now the House is admitting there isn’t going to be a replacement. So now the choice falls to Republicans to either defeat repeal, or allow the system to hurtle toward chaos.
Update: The Washington Post has obtained a recording of House and Senate Republicans meeting over how to proceed on Obamacare. The meeting, held privately, suggests that Republicans have even less idea over how to proceed than their public comments suggest. There appears to be no consensus on anything. Can Republicans repeal the law through a budget-reconciliation bill, and then try to pass a replacement later? They don’t know. (“The fact is, we cannot repeal Obamacare through reconciliation,” says Representative Tom McClintock. “We need to understand exactly, what does that reconciliation market look like? And I haven’t heard the answer yet.”) Are they going to keep the law’s expansion of Medicaid? They don’t even agree on attaching a measure to defund Planned Parenthood.
Numerous members expressed fears about the backlash they would face by snatching coverage from 20 million Americans. They have spent eight years promising to implement something better, and the Republican Party is still gawking at a whiteboard trying to figure out step one.