It’s worth dwelling on what we’ve learned over the past few months in order to understand what is coming next
Why the War Over Health Care Isn’t Over
he Trump era has conditioned us to brace for chaos, upheaval, and the next story. On Tuesday, after Mitch McConnell, the Senate Majority Leader, decided not to schedule a vote on a last-ditch Obamacare-repeal bill put forward by Senators Lindsey Graham and Bill Cassidy, it took only a few hours for the political world and much of the news media to move on to the next item on the White House’s agenda: tax reform. But, before running forward into this new legislative battle, it’s worth dwelling on what we’ve learned over the past few months, as successive G.O.P. health-care bills have faltered. Some of the lessons are encouraging, and some aren’t. Let’s start with the uplifting stuff.
Seven and a half years after Congress passed the Affordable Care Act, the central value it enshrines—that affordable health care should be available to everyone, regardless of age, income, or medical history—is now widely accepted. Opinion polls show almost universal support for this proposition. Donald Trump says he supports it, and so do Republican leaders such as House Speaker Paul Ryan (although they tend to use weasel words like “accessible” rather than “affordable”). That is why the Republicans got into such political trouble when—after years of promising to repeal Obamacare—they finally had to release details of their plans for doing so. It turned out that their ideas would lead to millions of poorer Americans losing coverage, while many seniors and sick people would see their out-of-pocket costs soar. The Party’s hypocrisy was exposed.
Another progressive idea included in the A.C.A. that has proven durable is the notion that expanding health-care coverage is important enough to justify higher taxes on the wealthy. When Donald Trump took office, Republicans were determined to repeal two Obamacare tax increases that had hit households earning more than a quarter of a million dollars a year: a 0.9-per-cent surcharge on Medicare taxes and a 3.8-per-cent investment tax. These increases had helped pay for the law’s insurance subsidies and its big expansion of Medicaid. Yet going after these tax increases left Republicans open to the accusation that their real motivation was to help the Party’s wealthy donors. After McConnell’s Better Care Reconciliation Act died, in mid-July, Republicans quietly stopped pushing to get rid of these taxes. McConnell’s so-called “skinny repeal,” which was voted down in the early hours of July 27th, and the Graham-Cassidy bill both would have left these taxes in place. For a Republican Party that views cutting taxes on the rich as one of its central missions, that was a big retreat.
The general point is that the enactment of Obamacare, despite all the criticisms it has received, has permanently shifted the political debate. It is no longer enough for Republicans to argue that America can’t afford a decent health-care system, or that the way to fix things is to simply repeal the A.C.A. and leave the rest to the market. Having seen the pluses and minuses of Obamacare, most Americans aren’t willing to junk it in exchange for vague promises. Any potential replacement must be able to withstand some detailed comparison shopping. Thus far, no Republican plan has been able to meet that challenge.
The ubiquity of the Internet has played a role here. As the action on Capitol Hill proceeded, practically everybody had access to the latest health-care analyses from independent institutions like the Congressional Budget Office, the Kaiser Family Foundation, and the Commonwealth Fund. Most people didn’t actually read the studies these organizations produced, of course. But the news media helped transmit the key findings, and so did the round-the-clock social-media efforts of experts including Kaiser’s Larry Levitt, the former Obama Administration official Andy Slavitt, and the Center for American Progress’s Topher Spiro. The C.B.O.’s studies, which showed that the G.O.P.’s plans would lead to big drops in coverage and much higher premiums for people older than fifty-five and those with preëxisting conditions, were arguably the single biggest factor in public opinion turning against McConnell and Ryan’s efforts. This month, when the Republicans tried to rush through the Graham-Cassidy bill, they scheduled things so that the C.B.O. wouldn’t have enough time to do a proper scoring. But this tactic rebounded: it was widely, and rightly, seen as subterfuge.
For once, real news and real analysis won out over fake news, and democratic activism defeated procedural stunts on Capitol Hill. On Tuesday, I noted that health-care-advocacy groups and Democratic activists had for months pursued Senator Susan Collins, of Maine, putting pressure on her to vote against her Party’s bills.
Of course, Collins might have decided to oppose the Republican repeal bills even without the protests. (And, as I noted, the nation owes her its thanks.) But there can be no doubt that the activism had an effect. Think back to what happened during April and May in the House of Representatives, when Paul Ryan, trying to pass his American Health Care Act, faced defections from moderate Republicans who represent places such as New York, New Jersey, and Pennsylvania, and who were being subjected to regular protests in their home districts. Ryan ultimately got his plan through the House, but the wider repeal effort never really recovered its momentum.
On the other side of the ledger, it must be acknowledged that, as the Duke of Wellington is reputed to have said of the Battle of Waterloo, it was a damn close-run thing. Had Collins, Lisa Murkowski, or John McCain voted the other way on the “skinny repeal,” back in July, the legislation would have proceeded to a House-Senate conference, where it would probably have been broadened and passed. We don’t know for sure how many Republicans would have supported the Graham-Cassidy bill if it had come to an actual vote, but it surely would have been close, too. Republicans have comprehensively lost the intellectual arguments: they can’t cite a single reputable study showing that their bills would preserve affordable coverage for the old, the sick, and the poor. But that doesn’t appear to be enough to sway most G.O.P. senators. Either because they feared primary challenges from the right or because they had trotted out the anti-Obamacare patter for so long that they had come to believe it, the vast majority of them toed the Party line. Especially after Tuesday’s Senate primary result in Alabama—where the insurgent Roy Moore defeated the Party favorite Luther Strange—there is no reason to expect this attitude to change. And there’s also no reason to believe that the Republican Party won’t, at some point, launch yet another repeal effort. In fact, it is only a question of when.
On Wednesday, Lindsey Graham, who had just watched his bill die, said that the Party would return to health care immediately after passing tax reform. But a legislative window for pushing through a health-care measure with just fifty votes is closing, and, going forward, the Republicans will need sixty votes to break a Democratic filibuster. Unless, of course, they pass another budget-reconciliation bill, which would give them another chance at a fifty-vote victory. Or they could get rid of the filibuster altogether, a step which Donald Trump urged them to do on Wednesday.
For now, it looks like the next repeal effort will have to wait until after the 2018 midterms. But another thing we’ve learned in the past few months is that you should never underestimate the determination of the Republicans, and of their wealthy donors, to dismantle Obamacare, or their eagerness to embrace practically any tactic that might help them achieve their goal. “Bottom line is the ACA is not remotely safe between now & 2018 election,” Andy Slavitt tweeted on Wednesday. The forces of enlightenment and progress have won another big battle. But the war isn’t over.
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