The Republican Party has waged a ceaseless war to destroy health-care reform since the debate began in Congress more than seven years ago. Before the bill passed, Republicans demanded it be scrapped so they could “start over” and craft a fresh bill that solved the problems in the system and didn’t include any of the particular policies they found objectionable. After Obamacare passed, they demanded the same thing — a full repeal and replacement with something better. Now they face catastrophic success: an election that has handed them the power to carry out their demands.
Exactly what course of action they will follow is hard to say. Donald Trump, his advisers, and Republicans in Washington have floated an array of ideas and promises, many of which are mutually exclusive, and all of which face enormous obstacles. Because they have no good options, the choice they settle on, as ridiculous as it may sound, may be to delay their decision another two years.
Trump’s campaign rhetoric on health care was a slightly amped-up version of the standard Republican line. Obamacare was a catastrophe, and he would immediately destroy it and replace it with “something terrific,” which he frequently defined to mean health care that takes care of everybody’s needs but at lower cost. The main trouble is that neither the standard-issue Republican promise of a better plan, nor the more grandiose Trumpian version, can actually be created.
Health-care coverage is a relatively straightforward problem of resource allocation. Tens of millions of Americans can’t pay for the health care they need, because they either have low incomes or expensive medical needs. There are many different ways to fill in the gap between what they need and what they can afford on their own. You can do it through straight taxes and spending. Or you can do it through regulation, forcing insurers to charge healthy customers more than they cost so they can charge the unhealthy ones less. Obamacare uses both of these methods. Republicans oppose both of them.
The Republican approach involves endless rhetoric about “choice,” “competition,” “markets,” “patient-centric” care, and so on. But none of these concepts has the magic power to conjure resources out of thin air. So when Republicans design alternative plans, and they have sketched out quite a few, inevitably they just provide fewer resources. The most popular concepts among Republicans involve allowing insurers to charge less to young or healthy customers, and to require them to cover fewer essential benefits. Of course, you can save money for young and sick people by letting them buy skimpier plans. But that just shifts the cost of care onto the old and sick.
This is why the Republican Party has failed to unify around a single alternative despite seven years of promises that they can produce a better plan. There are, of course, Republican plans, but the plural is key. The existence of many plans means no individual Republican can be held accountable for any single one. And the plans lack anything close to the specifics of the actual law signed by Obama. Republicans have a lot of concepts and frameworks, but not much in the way of numbers. Voters can’t figure out what kind of insurance they would get or what it would cost them.
Conservative health-care advisers all admit that the Republican alternative remains elusive. The Washington Examiner’s Philip Klein: “Though there are many ideas for such an alternative, Republicans haven’t settled on a single one.” Usually, they concede this problem in passing. “These differences can be debated and resolved in the new Congress. But if repeal is successful, Republicans will be in a position to sort out those disagreements,” insist Republican health-care advisers Tevi Troy and Lanhee Chen. “Although repealing and replacing the ACA is closer than ever before, many important details will have to be worked out in the next few months,” note another pair of conservative health-care advisers. If it were easy to resolve these wee details then it would have happened sometime over the last seven years.
There is also a mechanical problem on Senate rules facing the would-be repeal-and-replacers. Republicans alone have the ability to wreck Obamacare quickly, but not necessarily to replace it. The reason is that the law writes rules that create health exchanges where people can buy insurance, and rules designed to ensure that insurers can’t charge more to people with preexisting conditions or deny coverage for important treatments. Those rules were passed with a House majority plus 60 votes in the Senate to overcome a Republican filibuster. Repealing those rules would also require overcoming a filibuster.
There are two ways Republicans can get around this barrier. One would be to abolish the filibuster by a majority vote, allowing them to pass any law they want with a majority, which they control. The trouble is that some Republicans like the filibuster and may be reluctant to eliminate it, at least not right away. Another tool Republicans have is a budget reconciliation bill. That’s a special category of legislation that can be used only for matters of taxes and spending. Republicans could use a reconciliation bill to eliminate the subsidies that make Obamacare work, but not the insurance protections (which are regulations, not taxes or spending.) So reconciliation would mean Obamacare is on the books, but starved of funding. Such a crippled, dysfunctional system would pose a humanitarian and economic catastrophe for which Republicans could be held responsible by voters.
So how will Republicans handle it? One possibility is to compromise with Democrats. Republican staffers speaking to reporter Caitlin Owens said they would not use the repeal bill their party had sent to Obama endlessly for vetoes. (“We’re not going to use that package. We’re not dumb,” said one.) They described their approach as “more massive reform” and “a rewrite of Obamacare.” The plan they loosely describe would keep Obamacare’s structure, and change the law to make it friendlier to Republican priorities. They could strip out some of the essential benefits required by the law. They could allow insurers, who are now allowed to charge older customers no more than three times as much as they charge a young one, something more (like, say, five times as much). And they could change the subsidies in a more Republican-friendly way — which generally means making them more generous to the affluent and stingier for the poor. This kind of compromise would impose a lot of hardship on vulnerable people. (A good summary of the impact of these changes can be found here — it would hurt more people than it would help.) But it might attract some Democrats eager to sustain some kind of safety net for the health-care system. Republicans could satisfy the blood lust of their base by framing this as a “repeal” of the law and a replacement with a somewhat altered version.
After he met with President Obama, Trump seemed to endorse a version of this strategy. “We’re going to do it simultaneously. It’ll be just fine. That’s what I do. I do a good job,” he said. “We’re not going to have like a two-day period and we’re not going to have a two-year period where there’s nothing. It will be repealed and replaced. It’ll be great health care for much less money.” As is often the case, Trump’s verbiage did not convey any clear and definable course of action. But to the extent meaning could be extracted, he was promising not to pass a quick repeal bill or to wreck the law completely.
Yet such a course of action seems likely to enrage conservative activists, who could ignite a firestorm of protest against the sellout leadership capitulating to nefarious congressional Democrats. Indeed, much of the conservative movement has invested itself heavily into the notion that Obamacare is an act of singular evil that must be destroyed — the very impulse that prevented Republicans from negotiating on the law in the first place.
And so a second course of action seems more likely. Republicans would quickly vote, through a reconciliation bill, to dismantle the law’s subsidies. They could do this in a massive reconciliation bill that also advanced other priorities, like a large upper-bracket tax cut, cuts in spending on anti-poverty programs, defunding agencies that regulate Wall Street, polluters, and so on. But the defunding of Obamacare would be delayed for two years, until after the 2018 midterm elections, to shield the GOP from the political impact. In the meantime, Trump could deliberately impair the law’s functioning through administrative action, so that the exchanges lost customers rather than gained them.
This plan would give Republicans two more years to design their alternative. By 2019, they would likely have eliminated the filibuster over some other dispute. If not, eliminating the law might give them leverage to try to force Democrats to participate in some kind of ultra-threadbare replacement plan. The leverage would be that, if they fail to support it, Obamacare would disappear without anything at all taking its place. When thinking through the Republican Party’s incentives, the option that makes the most sense is the immediate repeal vote with a two-year delay before it takes effect.
This plan would also jibe with an important and underappreciated aspect of the right’s critique of Obamacare. I’ve read hundreds, perhaps thousands, of conservative attacks on the law. Invariably, they refuse to contrast it with the actually existing health-care system it replaced, which was the cruelest and also the most expensive in the world. Instead they contrast it with an imagined Republican alternative. Repealing Obamacare, and thus cratering the health-care system, and then building an alternative much later would free Republicans from having to design a system, with actual specifics and real dollars, that compares favorably to Obamacare. It would merely have to be better than the rubble they themselves created.
Kellyanne Conway endorsed holding a special session to repeal the law on Inauguration Day. A day-one vote would make it impossible, of course, to enact any replacement.
Repeal-and-delay would allow Republicans to enjoy all the benefits of the stance they have maintained since the debate began. They would demonstrate their firm anti-Obamacare conviction, eliminating any protest on their right flank. They would avoid responsibility for the real-world impact of their vote, since they could continue promising “something terrific,” without any quantifiable trade-offs in its place. The most important dynamic of the health-care debate is that Republicans have no plan that can meet the public’s minimal humanitarian health-care-access needs. Having control of government is not going to change that.