Let me get this straight. Last night, Republicans in the Senate were virtually paralyzed with the fear that the bill on which they were voting “aye” might actually become law. They were so terrified, in fact, that some key senators would only vote for the measure with House Speaker Paul Ryan’s assurances that his chamber would never pass “skinny repeal” outright. Only by the slimmest of margins did the bill that no one wanted to see become law fail when Senator John McCain surprisingly voted “no.” And now everyone is mad at McCain for killing a bill that they all hated anyway.
This confused and humiliating debacle puts a period on the GOP’s first attempt to repeal ObamaCare by applying the political capital they’ve accumulated from six years of promising to repeal it. The word “first” is key. Many assume that the GOP now has a choice; maybe they rethink the reformation of the Affordable Care Act (or try another attempt at repeal), or maybe they move on to other items on the agenda. The reality is that health care is never going to go away for either party.
Republicans are now obliged to administer ObamaCare. A Republican-led White House oversees subsidies to insurers to defer the cost of low-income ObamaCare enrollees. Donald Trump has on more than one occasion threatened to close off the spigot and allow ObamaCare to wither on the vine. The GOP in Congress, too, will have to own the Affordable Care Act. Every time they pass a budget or a continuing resolution, they will be ratifying the Affordable Care Act’s taxes and passing that on to the president to sign.
Even absent Republican meddling, ObamaCare is not stable. Despite an infusion of $2.4 billion in tax dollars, 20 of 24 ObamaCare non-profit health insurance cooperatives have collapsed. The National Alliance of State Health Cooperatives, which represented those cooperative efforts to compete with private sector insurers, has closed its doors.
Insurers continue to flee the Affordable Care Act’s insurance exchanges. When Trump took the oath of office, there were 1,000 counties served by only a single insurance provider (with a handful of counties utterly bereft of participating insurers). That trend has only accelerated. Amid an exodus, Iowa’s last major Affordable Care Act insurer threatened to pull out of the exchanges—leaving the state without ACA-linked insurance in 2018. In May, Aetna abandoned Virginia. Humana pulled out of Tennessee in February. Blue Cross Blue Shield has picked up the slack in some places but, in Alabama, for example, it spends $1.20 for every $1 it collects in premiums. This is not a sustainable status quo.
Democrats appear genuinely convinced that the 1,000 seats their party lost over the course of the Obama years were the result of mass hysteria from which the nation has finally awoken. They seem to think that the fever has broken, and the public is now convinced that this onerous law is popular in its own right and not just when compared to Republican alternatives. The system is broken, and someone has to repair it. Even if it becomes the Union siege of Fredericksburg, in which wave after wave was mowed down by dug-in defenders, Republicans are obliged to keep making runs at Obamacare. The Democrats, too, will have to “fix” the law, as so many insist they must. By 2016, even Barack Obama and Hillary Clinton were resigned to the fact that legislation to relieve the stress on insurers was an imperative. But what the Democratic Congress wants isn’t what the party’s liberal activist base wants.
Republicans performed a politically savvy maneuver on Thursday evening (yes, just one) by compelling their Democratic counterparts to vote on a “Medicare-for-all” single-payer national health plan. The bait drew precisely zero votes in favor, with 43 Democrats opting only to vote “present.” Centrist Democratic Senators Heidi Heitkamp, Joe Manchin, Jon Tester, and Jo Donnelly and Independent Sen. Angus King contributed to a total of 57 “no” votes. Congressional Democrats’ trouble getting to yes on single payer isn’t all about tactics. A June effort to pass a single-payer system in the state of California failed because, as Democratic Assembly Speaker Anthony Rendon wrote, it failed to address major hurdles including delivery of care, cost controls, and, most important, financing. The program was estimated to cost $400 billion per year—more than twice the state budget in 2017. At a national scale, a single payer program would be a struggle to finance. Democratic lawmakers may soon find themselves as shackled to the unrealistic hopes of their base voters as are Republicans today.
Republicans surely would like to move on to reforming the tax code for the first time since 1986, but that won’t be a simple task. All the while, the taxes in the Affordable Care Act and the revenue dedicated to it will hinder their efforts. Democrats, too, would love to be able to move on from the Affordable Care Act, but they are similarly doomed forever to tinker with “fixes”—at least until their liberal base voters cobble together a party in which nationalized health care is the consensus. Even if lawmakers wanted to move on from health care, they can’t.
