he effort to repeal Obamacare came tantalizingly close to fruition. Republicans succeeded in passing a bill in the House, only to fall just a few votes shy on a different bill in the Senate. But had that hurdle in the upper chamber been overcome, a president in the White House was ready with pen in hand to sign almost any negotiated settlement sent to him by the GOP House and Senate. Instead, Obamacare survived. More than survived. It became politically stronger in the course of the debate and its aftermath, and in the wake of the Republican failure, a more radical measure even more pleasing to the left has suddenly been infused with new life.
The episode is a case study in the challenge of rolling back the welfare state. Republicans believe as a general rule that government provides too many services and should be pared back—but is there any specific case in which their elected officials are willing to attempt such reforms? If the Republicans could not repeal Obamacare at a time when they hold the House, the Senate, and the White House, and when nearly all of these GOP officials were elected in no small measure on the basis of their personal commitments to repeal and replace Obamacare, when might they ever repeal it—or any large-scale government program? As GOP policymakers ponder what comes next, they might consider the fact that, while they will remain the only game in town when it comes to resisting the growth of government, educated voters are unlikely to accept any future promises that Republicans might make about shrinking government’s size.
he GOP effort to repeal and replace Obamacare in 2017 was flawed from the start. The Republican leadership on Capitol Hill chose the formal “budget reconciliation” process as the legislative path to force a replacement of the Affordable Care Act. It is the only way a bill can pass the Senate with a simple majority (without having to weather an initial “cloture” vote ending debate on a measure, which requires 60 votes). There are 52 Republican senators, and there was no chance of securing a single Democratic defection. Under these conditions, Republicans needed to be in a state of almost total unanimity in getting rid of the old law and finding another, better approach. It turned out that too many Republicans were too nervous about what might come next to agree to Obamacare’s complete elimination. Meanwhile, there were too many anti-Obamacare stalwarts who would have voted against merely cosmetic Band-Aid fixes to the law to make a face-saving “we’re doing something” a possibility.
Some critics have argued that the GOP flopped on health care because the party was not prepared for victory in 2016. Preparation was not the problem. House Republicans, under the direction of Speaker Paul Ryan, had been working on an alternative health plan in case the Republicans won the 2016 election. Ryan’s plan, labeled “A Better Way,” stitched together most of the standard Republican reform ideas: a refundable tax credit, expanded Health Savings Accounts, the ability to purchase health insurance across state lines, medical-liability reform, and allowing people to band together to purchase insurance in association health plans. But only some of those policy elements could be passed through the reconciliation process, under which every measure must have a direct budgetary impact on the federal government. The bill that finally succeeded in the House was necessarily a patchwork quilt rather than a comprehensive approach.
More problematic, and to a degree heretofore underappreciated, were stark differences within the Republican ranks. For the past seven years, Republicans denounced Obamacare, nearly unanimously, and claimed they would repeal and replace it if elected. It was a standard, and immensely popular, talking point in almost every Republican campaign. What is more, Republican leaders in Washington may have assumed that elected officials had signaled implied consent for the Ryan plan. Because there were no official condemnations of it within the GOP caucus before the surprise results of the 2016 election, Ryan and others likely had a false sense that there was consensus among Republican legislators on both repealing and replacing Obamacare. But when the GOP bluff was called by an electorate that handed the Republicans total control, some Republicans blinked, and in sufficient numbers to sink the entire project.
More discomfiting still, Republicans found themselves unable to make the honest case that passing any of the bills before the House and Senate actually made for good policy. The arguments for the bills tended to center on process and raw politics. Republican legislators were told by their leaders that they needed to pass something because the GOP had promised “action” on health care and that a failure to do so would reveal Republican impotence.
The bills with which they were presented, however, were impotent themselves in fundamental ways. None of these measures would have done a thing to drive down the cost of insurance premiums in the short term. And as a matter of practical politics, no GOP legislator who wanted to keep his promise could seriously claim that any of the bills would have repealed all of Obamacare.
It is true that almost all of those who would have had no problem voting for a total repeal did vote for one of the alternatives. But they could not strongly advocate the legislation without looking false or hypocritical. Nor would any of the alternatives drive down the cost of insurance premiums in the short term.
Meanwhile, Democrats were arguing relentlessly that the Republican bills would end health care for tens of millions, using two studies from the nonpartisan Congressional Budget Office as their battering ram against the GOP. When comparing the number of people “covered” under Democratic and Republican health proposals, Democratic initiatives “cover” more people.
The CBO’s analysis found that 15 million people would “lose” coverage solely because the GOP bills would have ended the Obamacare “individual mandate”—the law mandating that everyone in the country purchase coverage whether they wish to or not. (Overall, the CBO found that the GOP bills would drop 22–23 million from coverage). The CBO did not take into account the potential impact of cost- and quality-based incentives. Instead, it focused on the linear effect of the federal government’s power to demand that something happen and then make it so. With this as the dominating assumption of their studies, all Republican attempts to incentivize Americans to buy health care by lowering costs and increasing choices were found wanting.
There is a fundamental flaw to the CBO’s logic. First, people who would have chosen of their own free will not to buy coverage could not properly have been said to have “lost” coverage or have had coverage “taken away” from them. Second, if better coverage at lower prices could result from building a more robust and competitive market, the product itself would generate customers in massive numbers that the CBO’s entirely static analysis could not possibly foresee.
And yet it is impossible to deny that Republican plans designed to reduce the involvement of the government in health care would result in fewer people receiving coverage from the government. If you are going to subsidize something and require the purchase of that something, you will get more of it. Democrats are willing to spend more, to provide costlier subsidies, to subsidize people at higher levels of income, and to mandate that people purchase coverage. This is what Obamacare did. But in doing so, Obamacare has not provided better care, or affordable care, or even accessible care. Its results have been parlous. But the number of people who report having insurance is unquestionably higher than it would have been if nothing had changed in 2010. And when the argument devolved to the binary question of whose plan would cover more people, the Democrats won.
epublicans are now scrambling to figure out what, if anything, they can still get done on health care. Some, like Senator Lamar Alexander of Tennessee, are seeking a bipartisan solution that would likely include additional funding for Obamacare subsidies to stabilize its failing state-level exchanges and without significant conservative reforms that would cause Democrats to balk. Some conservatives are looking for another attempt to repeal the ACA, but they lack an explanation for how taking the same approach again would bring about different results.
While Republicans scramble, Democrats flush with victory will not stand pat in the months ahead. They will take the opportunity created by the GOP’s failure to move aggressively in the direction of single-payer health care on the model of Canada’s or Great Britain’s. Such a system would be more government-directed, more Washington-centric, with less choice, fewer incentives to develop life-saving cures, and more rationing than our current system. But Democrats are optimistic that Obamacare’s many problems, coupled with the Republican failure to deliver on a workable alternative, are creating a path. Liberals may celebrate the salvation of Obamacare, but they know it is unworkable in the long run.
Furthermore, the way the debate has shifted is smoothing the path to single-payer. If coverage is the ultimate good, a system that “guarantees” coverage with no exceptions will have a leg up in all arguments, regardless of its impact on cost, quality, access, and freedom. The success of Democrats in pushing the coverage issue to the exclusion of all else, combined with a Republican inability to counter the Democratic arguments, has brought us to a point when single-payer is more likely than it has ever been—despite the Republican electoral triumphs over the past seven years.
Those triumphs mean that Republicans have the presidency through 2020, of course, and control of the House and the Senate through at least 2018. But if Democrats manage to recapture the House, Senate, and White House after the 2020 election—a not implausible scenario given President Trump’s historically low approval ratings—it appears single-payer will be one of their top legislative priorities.
Democrats have long been wary of single-payer, not so much for ideological reasons, but out of concerns that it was a political loser. In his recent book, Al Franken: Giant of the Senate, Minnesota Senator Al Franken notes that “the simpler solution would’ve been to just go to a national single player plan like Canada’s; Medicare for everyone.” But, he writes, the problem with such an idea in 2009 was that “we needed 60 votes to pass anything, and we were, oh, about 50 votes short.”
Add to that hesitation the real-world experiences with single-payer in the United States, and you might think Democrats would continue to be wary of it. In 2011, Vermont passed a single-payer plan called Green Mountain Care. Vermont’s Democratic governor pulled the plug on it three years later, citing high costs and the concern that going forward with the plan at that point might have harmed Vermont’s ability to secure a different single-payer plan in the future. In 2016, a single-payer ballot initiative in Colorado went down to defeat. And California’s State Senate recently passed a single-payer bill called Healthy California, only to have it shelved in the State Assembly by Democratic Speaker Anthony Rendon.
But there is evidence that the tide is shifting. California progressives threatened a recall campaign against Rendon, who subsequently called for hearings on universal coverage to take place this fall. Kamala Harris, California’s newly minted senator, announced at the end of August that she would introduce single-payer legislation—a grandstanding move indicating that her almost-certain 2020 presidential bid will be devoted to the issue. She is trying to get ahead of Bernie Sanders, who has promised to present the Senate with a version of a “Medicare-for-all” measure co-sponsored by more than 100 House Democrats. Sanders said recently that the pursuit of single-payer “is a fight that has to be waged, because it is the only rational solution to the health-care crisis that we face.” Senate Minority Leader Chuck Schumer said on ABC’s This Week “We’re gonna look at broader things: Single-payer is one of them.” Franken’s 2009 pessimism is a thing of the past.
To be sure, the Democrats still face major obstacles in this regard that go beyond Republican domination of the government. Not only has single-payer been consistently unpopular with American voters, it also faces a host of logistical hurdles. The transition away from our current, admittedly imperfect system would probably be disruptive for millions. Remember this essential fact about our current system: The majority of Americans have employer-sponsored care, and they are, by and large, happy with their coverage.
A single-payer plan would also be incredibly costly. Even the attendant tax hikes necessary to pay for it would be insufficient to cover the increased costs. California’s aborted plan would have had the government cover premiums, copays, and deductibles. Lack of consumer involvement would mean even more costly health care than we have seen thus far.
A single-payer plan with more cost controls would cause massive problems of its own. Government-run programs such as Medicare and Medicaid reimburse doctors for their services at lower rates than private-sector insurance does. This is why we frequently hear about doctors refusing to take on new Medicaid patients: It is often not worth their while to accept new patients they are not paid enough to treat. A single-payer system would exacerbate this problem. All doctors would, in essence, become employees of the government. They would be subsumed in a rationing system—in which the care they provide would be governed not by their relationships with patients or their own decision-making but by the rule of the queue. All of this could lead to a wholesale departure of medical professionals from the system, with consequences we cannot begin to imagine.
Even with all the challenges ahead, the Republican failure to pass any kind of health-care alternative is still a political disaster of the first order. It has left Obamacare in place, stronger politically than it has ever been because it is more popular than any Republican alternative. This is a double whammy: Republicans are now tagged both with advancing approaches no one likes and an inability to get anything done. A recent headline in the Onion may have summed it up best: “Repeated Attempts at Eradicating Obamacare May Have Created Ultra-Resistant Super Law.”
We are now in a place where Obamacare is the new baseline, and the battle ahead is likely to be over an even more intrusive system. If an effective battle against single-payer is going to be waged, that battle would have to come from Republicans. From what we have seen thus far, it is not at all clear that the Republicans will be able to wage that fight successfully unless they hold on to power indefinitely. What should have been a long-sought GOP triumph has instead brought us closer than ever to single-payer health care, the fondest desire of the American left and the waking nightmare of America’s conservatives.