Watching President Donald Trump on Tuesday, as he arrived at the Capitol and prepared to rally House Republicans around replacing the Affordable Care Act, it was hard not think about a similar occasion almost exactly seven years ago: Former President Barack Obama went to Capitol Hill in March 2010 to urge House Democrats to pass the very legislation Republicans are now trying to wipe away.
But the differences are more striking than the similarities. They reveal a lot about which party is more serious about policymaking ― and which one actually cares about helping people get health care.
And now the question is whether those differences will determine the fate of House Republicans’ American Health Care Act.
Democrats Had Overcome Their Divisions
By the time Obama made that visit in 2010, the House and Senate had already passed their versions of health care reform. The Senate did so with a 60-vote supermajority, in order to overcome a Republican filibuster. Nancy Pelosi, the California Democrat who was speaker of the House at the time, hadn’t quite sold her caucus on voting for the Senate’s less generous, less progressive version. But she was close.
Democrats understood that moving forward had political peril. They had gotten a taste of electoral defeat that January, when a special election in Massachusetts put the late Democrat Edward Kennedy’s old seat in the hands of a Republican and set in motion the chain of events that led to that March vote on the House floor. But Democrats were also leading quite a large posse, including pretty much every organization that represented either the people who provide health care (like the American Medical Association and the American Hospital Association) or the people who most frequently consume it (like AARP and the American Heart Association).
It had taken time to build that coalition, just as it took time to craft the legislation ― and to work through all tradeoffs of politics and policy. (When Obama was thinking through the complications, he’d twist an invisible Rubik’s cube in the air, Vox noted recently.) Working within parameters the Congressional Budget Office had set, Democrats ended up with a plan that, by the CBO’s reckoning, would expand coverage and reduce the deficit ― just as they’d always promised.
But perhaps most importantly, the Democratic Party, for all of its misgivings and internal ideological divisions, was largely united around its vision for reform. It had been since the beginning of the legislative effort. After more than a year of intense debate in Congress, the party was also resolute in its determination to finish the job ― to take a giant leap on a journey that had begun three-quarters of a century before, when Harry Truman launched the first formal effort at creating a national health insurance program.
And the leap worked, in large part. The ACA, or Obamacare, slashed the national uninsured rate to a historic low by expanding health care coverage to 20 million people who didn’t have it before. Some people are paying more for coverage than they were before, and plenty are unhappy with their insurance. But access to care has improved and financial distress from medical bills has declined, according to multiple studies.
At the same time, national health care spending growth slowed to an unprecedented rate. That may have been related to the ACA, but even if it wasn’t, it occurred during a time when an increasing number of Americans had health coverage and received medical care.
Republicans Are Divided ― And Increasingly Isolated
Trump and House Speaker Paul Ryan (R-Wis.) may yet succeed in their effort to undo most of that. But they faces challenges that reflect upon their preparation, their seriousness and, ultimately, their priorities.
Nearly all of the groups that supported the ACA oppose repealing it. And some of them, like hospitals and the AARP, are fighting hard to preserve the new guarantees of coverage ― even as conservative groups fight the measure because they think it doesn’t dial back the coverage expansion enough.
Amid this torrent of criticism, support for the measure and the president championing is falling. Polls now generally indicate that voters want Republicans to slow down ― and that the ACA, seven years into its existence, is finally becoming popular.
Most striking of all, the Republican Party is divided. One day before the planned House vote, factions within the party are still arguing over fundamental questions ― and if those divisions don’t stop the bill in the House, they are sure to cause major problems in the Senate. Sens. Ted Cruz (R-Texas) and Rand Paul (R-Ky.) can’t stand the idea of leaving any of the Obamacare edifice in place, while Sens. Bill Cassidy (R-La.), Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) are saying they won’t vote for anything with such significant coverage losses.
That’s a massive ideological gap to close, dwarfing anything Democrats had within their ranks in 2009 and 2010. Senate Majority Leader Mitch McConnell (R-Ky.) has indicated he wants to bring legislation from the House directly to the floor, and amend it there, next week. It looks an awful lot like an attempt to rush the process even more than the House did, perhaps in the hopes that McConnell can force his caucus into voting yes before anybody quite grasps the full implications of the proposed law.
Obama could defend the core of his plan because he understood it and quite obviously believed in it. Knowledge meant power and control.
Ryan, among others, keeps suggesting that Trump will make it all happen. But Obama could successfully rally Democrats partly because he had been engaged on the issue, directly and substantively, throughout his presidency. In early 2010, when the bill was in its greatest political peril, Obama famously held forth on the plan details ― jousting with Republicans at a January 2010 party retreat in Baltimore and then in a February marathon bipartisan open meeting at Blair House, near the White House.
In the late stages of a legislative fight, rallying votes is more about politics than policy ― and, for sure, the Obama administration made plenty of quiet deals to keep wavering Democrats in the fold. But Obama could defend the core of his plan because he understood it and quite obviously believed in it. Knowledge meant power and control.
Trump has given no indication he has similarly strong feelings about the House bill ― or that he even understands it at more than a superficial level. He has said he wants the win, which is what he always wants. But the president repeatedly has made it clear that he’s not picky about what the win actually achieves, only that he wants it to somehow mean the end of Obamacare.
Republican Policies Don’t Back Up Republican Promises
In the absence of a deep substantive commitment to the details of the bill, the fallback rationale for passing it ― not just from the White House, but from other GOP leaders as well ― is that Republicans have to act because they promised to do so.
And it’s true. That is what Republicans have been promising for seven years.
But the GOP’s reverence for promises turns out to be curiously selective in this case, because Republicans also promised to “replace” the ACA. And they didn’t have just any old replacement in mind.
Over the years, Republicans attacked Obamacare for sticking people with high deductibles and premiums they could not afford. They promised to deliver better coverage ― offering the same Obamacare goodies, like protection for people with pre-existing conditions, without the unpleasant stuff like the individual mandate.
Trump was the most audacious of all, repeatedly saying thinks like “everybody’s got to be covered” and, during the transition, assuring a Washington Post interviewer that he wanted “insurance for everybody.” Polling and interviews have made it clear that many people, including a lot of Trump voters, took the promise seriously. If they didn’t truly expect everybody to be covered, they at least expected everybody’s coverage to be better.
This is not a promise he or the Republicans are going to keep.
If there were any lingering doubt about that, it vanished a week ago when the CBO issued its official analysis, predicting 14 million newly uninsured Americans within a year and 24 million within a decade. Republicans have told critics, and perhaps they have told themselves, that the estimate is wrong. But as Sen. Lindsey Graham (R-S.C.) pointed out at the time, even if the projection is off by a factor of two, that would still mean 12 million people losing coverage.
Republicans insist that their plan would reduce premiums, citing the same CBO report they disparage. The part of the story Republicans don’t tell is why the CBO thinks premiums would go down. It would predominantly be because older and sicker people drop increasingly pricey coverage, and because the market would gravitate toward less generous plans ― in other words, plans with even higher deductibles than the ones Republicans have been criticizing all these years. Were the Republican plan to become law, deductibles for the typical plan would rise by 60 percent to $4,100, according to a Henry J. Kaiser Family Foundation analysis that appeared in Axios.
If the bill ends up gutting insurance regulations more, as conservative members have urged House leadership to do, it would mean still lower premiums but still higher out-of-pocket costs, along with gaps in coverage for services like mental health and maternity care.
There is, of course, one policy promise that Republicans take seriously, and its centrality to the repeal crusade becomes increasingly apparent as the debate goes on: the vow to roll back Obamacare’s taxes, particularly new payroll tax “surcharges” that fall exclusively on the wealthy. This is a straight-up, one-to-one transfer of money from low- and middle-class people (who lose health insurance) to the wealthy (who get a tax cut).
Another new analysis, which the Urban Institute published Wednesday, looked at all the changes in federal revenue and spending ― the lower taxes on wealthy Americans, the loss of Medicaid and financial assistance for the poor and middle class. It found that households with incomes below 200 percent of the poverty line (about $49,000 per year for a family of four) would see net losses of income, while households with incomes above 300 percent of the poverty line (about $73,000 for a family of four) would see net gains. And families with incomes of six times the poverty line, or about $146,000 a year for a family of four, would see the greatest gains of all.
It is an almost perfect inversion of Obamacare, not that anybody should be surprised. Republicans spent seven years attacking the health care law and pretending they had a better way to protect the poor and the sick, even as they called for policy changes that would expose both groups to crippling medical costs. Writing legislation has revealed that contradiction once and for all. Republicans still have the votes to pass repeal. But if they do, they will be delivering something very different than they promised.