Republicans’ failure to repeal Obamacare, or even make major changes to it, feels over-determined. They came into the debate holding a weak hand, and they played it badly.
First: Voters have feared every attempt by politicians to change their health-care arrangements. That sentiment helped defeat President Bill Clinton’s proposed overhaul in 1994. It forced President Barack Obama to devote half his sales job on his health-care law to reassuring people they could keep their doctors and insurance plans. This year, public wariness of change worked against the Republicans.
Second: Democrats and the press played up how disruptive Republican legislation would be. They frequently said Republican bills would “take away” insurance from millions of people, citing the Congressional Budget Office.
That was a distortion. Under each bill the majority of those millions would have been people voluntarily forgoing insurance after the abolition of Obamacare’s fines for people who make that decision. A lot of the other people affected were in states that, the CBO guessed, might expand their Medicaid programs in the future if Obamacare stays. Still, Republicans did very little to try to correct the record.
Third: One reason Republican politicians did not engage on the issue effectively is that, as a rule, they neither know nor care much about health policy. Historically they have seen the issue as a Democratic strength, to be avoided while they stay on their own safe ground of taxes, regulation and military readiness.
Fourth: Republicans avoided multiple opportunities to reach a consensus on how to replace Obamacare. Some Republican officials put forward plans in 2013 and 2014, but party leaders refused to embrace them on the grounds that candidates were better off being vague and the party’s presidential nominee would lead on the issue. This advice suited a party averse to thinking about health care.
Then the nominee ended up being Donald Trump, who knew and cared less about the issue even than most Republican politicians. He didn’t run on a serious health-care plan, and Republican elected officials did not consider his victory a reason to embrace any specific ideas about health policy.
Fifth: Some key Obamacare provisions had strong political support. Republican plans to lower premiums and abolish the fines required them to alter Obamacare’s regulations protecting people with pre-existing conditions. But the change alarmed those people. There are a lot of them in every state, and they are a sympathetic population.
Support for the regulatory protections among the public at large was broad but weak: Polls found that it melted away when people were asked about the trade-offs it involved, like higher premiums. And there were alternative ways of ensuring affordable coverage for the seriously ill. But a lot of Republican politicians did not want to face the charge that they were abandoning that group — and (see above) understood neither the trade-offs nor the alternatives.
Sixth: Republicans don’t have 60 senators, as Democrats did when they passed most of Obamacare. Any Republican bill was therefore going to have to comply with detailed Senate rules to avoid a filibuster. Republican leaders sometimes used that constraint as an excuse for not including controversial policies that some conservatives wanted. But the rules seem to have also shaped some of their legislation. Without those rules, Republicans might have been able to come up with at least slightly more popular bills.
Seventh: The process made the product even more unpopular. Republicans managed to spend most of a year on health care, but with enough stops and starts that every new bill was a rush job. At each point, getting it done took clear precedence over getting it right. Most of the bills were sprung on congressional Republicans and the public, with no specific sponsors who could answer for and defend them.
There were so many reasons to expect Republicans to fail that what’s truly surprising is how close they came. Their perseverance in the face of these pressures and the possibility that Obamacare will grow more unstable in the coming years suggest that this year may not be the last word on Republican attempts to replace Obamacare.
But to succeed in the future, they need to learn from this year’s pathetic failure.