The Health 202: Five lessons from the GOP’s failed effort to repeal Obamacare

 In U.S.

Some Republicans will forever carry a torch for repeal of the Affordable Care Act. But it’s hard to see how the door really opens again in the near future — at least as widely as it has been since the start of President Trump’s tenure. There’s just too much in the way.

The past two weeks on Capitol Hill perfectly illustrate the problem. Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) developed some momentum for their health-care bill after the meltdown in July around a previous measure guided by Majority Leader Mitch McConnell (R-Ky.).

But the same old problems were still there when push came to shove. Not enough moderates were willing to cut Medicaid spending. Independent analysts said the GOP plans would cause millions of Americans to lose coverage. And, of course, Democrats were shut entirely out of the process.

Senate GOP leaders emerging from their weekly lunch yesterday confirmed that they’d canceled a vote on Cassidy-Graham planned for today. The budget reconciliation bill they were going to use for it expires Sunday. They could still try to create space for ACA repeal in the tax code rewrite they’re going to attempt next — or even create another budget reconciliation bill to use for health care. But neither scenario is terribly likely.

“You can change the procedure but you can’t change the underlying terrain,” Tom Miller, a health-care fellow at the American Enterprise Institute, told me.

In their scramble to pass Cassidy-Graham, Republicans sacrificed momentum behind a bipartisan bill to stabilize next year’s marketplaces being crafted by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.). Prices for health plans are now officially baked into next year’s marketplaces in most states, as today is the deadline to finalize insurer contracts in the states using the federal marketplace,

Even so, Alexander said yesterday afternoon that he’ll attempt to revive the effort.

“I will consult with Sen. Murray and with other senators, both Republicans and Democrats, to see if senators can find consensus on a limited bipartisan plan that could be enacted into law to help lower premiums,” he said in a statement.

Yet nine months into the Trump presidency, Republicans are no more unified on their approach to health care than they were early this year, when they couldn’t even agree on whether to repeal and replace Obamacare at once or separately. In fact, you could argue their fault lines are even more clearly demarcated than before.

Some Republicans will never admit their long-touted goal of overturning Obamacare has been shelved.

“Was it over when the Japanese bombed Pearl Harbor?” as one GOP lobbyist put it to me.

President Trump isn’t giving up, tweeting this morning (Politico’s Seung Min Kim notes Sen. Thad Cochran (R-Miss.) missed the Monday vote because of a medical issue but is not in the hospital):

Others held out hope of a revival, as well. Morning Consult’s Eli Yokley: 

From Yahoo News’s Liz Goodwin: 

From the Washington Examiner’s Kimberly Leonard: 

Others are being more realistic about the situation:

From Sen. David Perdue (R-Ga.)

Sen. Lisa Murkowski (R-Alaska) tweeted that Cassidy-Graham ran up against a “hard deadline and a lousy process:”

Sen. Cory Gardner (R-Colo.) is now focusing on a repeal of just a small part of the ACA: its health insurance tax set to resume in January:

Sen. Rob Portman (R-Ohio) is supportive:

So is Sen. Tom Cotton (R-Ark.): 

For Republicans who are ready to move on, The Health 202 offers five lessons we see emerging from this debacle:

1. You can’t easily cut a government program that 69 million benefit from.

Nearly one-fourth of Americans rely on Medicaid to pay for their doctor visits, prescription drugs and hospital stays. Eligibility varied widely by state before the ACA, but the health-care law looped in a much larger segment of the population by allowing states to enroll childless adults earning up to 133 percent of the federal poverty level.

Republicans don’t like the situation — and make valid arguments about Medicaid’s cost burden on states — but they were scared stiff by the prospect of a political backlash had they passed any of several GOP health-care bills proposing big cuts to the program’s spending.

2. You can’t go up against the health-care industry and win.

Health-care spending accounts for around 18 percent of gross domestic product — and the government has projected it will reach 20 percent of GDP by 2025. The health-care industry — from drugmakers to hospitals to doctors to insurers to device manufacturers — is powerful and influential.

They turned out in force against virtually all the health-care bills Republicans in the House and Senate have proposed this year. Insurers remained pretty quiet about the proposals, but even they publicly rejected Cassidy-Graham last week.

3. You can’t replace concrete health benefits with a big question mark.

The weakness of the ACA is that it didn’t expand coverage as broadly as many hoped and it didn’t tamp down health-care costs. It has, however, ensured that when people buy coverage they are guaranteed it will cover a basic range of services. And they get income-based financial assistance to ensure they can buy plans to begin with.

Cassidy-Graham would have disbanded the marketplaces where this coverage is obtained, instead turning over the subsidies for these plans — along with the extra federal dollars for Medicaid expansion — over to the states to spend as they wished. Many states may have used the money effectively. But Republicans couldn’t guarantee that would be the case, or explain exactly how the dollars would be used.

The plan assumed that just another group of elected officials, namely governors, would improve health coverage and services, without providing certainty that they would. “Cassidy-Graham is saying we’re not going to tell you how this is going to turn out,” Heritage’s Miller said.

4. You can’t win with bad grades from the Congressional Budget Office.

For each of the GOP plans, the CBO estimated that more than 20 million fewer Americans would have coverage in a decade. Cassidy-Graham never got a complete CBO score; even so, the agency released a projection on Monday that it would mean millions fewer Americans would be covered.

5. You can’t take away protections for millions of Americans with chronic medical conditions.

All the GOP health-care bills considered this year would have expanded to varying degrees the ability of states to opt out of insurer regulations that ensure people with serious medical conditions can obtain and afford coverage.

This type of approach just doesn’t fly, when you consider that about 1 in 4 Americans have preexisting medical conditions that would have made it harder for them to get coverage before the ACA.

“Americans have come to accept the idea that people should not be excluded from coverage, be charged unaffordable premiums, or be denied essential services because they have preexisting conditions,” Washington and Lee health law professor Tim Jost said.


–Democrats and other supporters of President Barack Obama’s law breathed a big sigh of relief after the news that Cassidy-Graham wouldn’t get a vote:

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