The failure of the Republican Party to parlay its control of the White House and Congress into a repeal of Obamacare launched a predictable blame game in Washington. The Tea Party-inspired House Freedom Caucus, which opposed its party’s “repeal and replace” substitute, faulted House Speaker Paul Ryan, R-Wis. It turns out these three dozen conservatives were always more about “repeal” than “replace.”
President Donald Trump denounced the Freedom Caucus and House Democrats. This made sense, considering that these odd bedfellows joined forces to oppose the Ryan-crafted replacement legislation. Others blamed Donald Trump himself. His finger-pointing didn’t exactly put anyone in mind of Harry Truman-style “the buck stops here” leadership.
Nor did the president display the perseverance exhibited by the leader Trump said he wanted to emulate. As Ronald Reagan’s pre-eminent biographer noted recently, it took Reagan 323 days to get his 1986 tax reform bill through Congress, even though he enjoyed far higher job approval ratings than Trump and the bill had bipartisan support. This White House, with the concurrence of Paul Ryan, pulled its Obamacare substitute bill after 17 days.
Is the moral of the story that an inexperienced Oval Office occupant with a short attention span equals ineffectiveness? Perhaps. Another lesson of this fiasco may be more disquieting: What if the U.S. has simply become ungovernable?
To be sure, the whole subject of government-subsidized health care has tripped up Democrats for a long time — Republicans, too. Guess which prominent Republican said the following during the health care debate: “One of these days, you and I are going to spend our sunset years telling our children and children’s children what it once was like in America when men were free.”
The speaker was Ronald Reagan back in 1963 — long before the Freedom Caucus began throwing spitballs onto the ceiling of the Capitol — when Reagan was the official spokesman for the American Medical Association in its lobbying effort against the creation of Medicare.
Only a decade later, President Richard Nixon was putting the final touches on his Comprehensive Health Insurance Plan, which would have required private employers to provide basic health coverage to all employees, with the government stepping in to insure the poor and the unemployed through a Medicaid-like program. Sound familiar? It should — it was an early version of Obamacare.
“There is widespread support in the Congress and in the nation for some form of comprehensive health insurance,” Nixon said in a February 6, 1974, statement to Congress. He was right, but Sen. Edward Kennedy, D-Mass., bottled up the White House plan. Kennedy, who later regretted his stubbornness, was holding out for a single-payer plan.
The point is that who should pay for health care and how it should be provided has long been an ideological touchstone for both major political parties. The sheer size of the industry — the trillions of dollars it consumes, its constant technology-driven changes — not to mention that millions of lives are at stake in getting the public policy just right, mean that even if Congress were populated by 535 altruistic independents with no further political ambitions, this would be a very difficult issue.
But the Affordable Care Act that President Barack Obama signed into law on March 23, 2010, was passed on a straight party-line vote. Fixing its flaws has been beyond the ken of the nation’s two major political parties, which scarcely know how to negotiate anymore.
One reason is that the intellectual polarization in each party is real, and a barrier to compromise. Both the Senate and House are full of members who won’t stand up to their party’s ideologues or financial backers. Moreover, House leaders operate under a hoary guideline called “the Hastert rule,” which holds that the party in charge won’t move legislation unless a majority of that party’s members approve. This recipe for gridlock is named after disgraced former House Speaker Denny Hastert, R-Ill. Here’s an alternative idea: Any rule of thumb named after a convicted child molester should be ignored.
But back to Obamacare. In the ACA debate, all the attention was on the 40 million to 50 million Americans who lacked health care coverage. They included young (usually healthy) people who opted out to save themselves money, the working poor who couldn’t afford insurance, those between jobs and self-employed Americans, some with pre-existing medical conditions.
The new law prohibited health insurers from discriminating against those with pre-existing conditions, earmarked billions of dollars for Medicaid so that states could offer medical care to those at 135 percent of the federal poverty level, and required Americans to purchase insurance. This last feature was the notorious “mandate” that existed primarily so that all Americans — even healthy millennials — would pay into the system, and help underwrite the rest of it.
So what have been the problems? Well, there are several, but I’ll mention three.
First, if the government requires you to purchase something, the government must define that something. The definition of health insurance proved to be a sticky wicket. The debate centered on those without insurance. But the government’s definition ensnared millions of people who already had it. Why? Because a plan that met the federal requirements now had criteria ranging from birth control and mental health benefits to physical therapy. These are all good things, but they added costs to less encompassing plans — and raised the premiums of Americans who already had insurance.
Defenders of Obamacare say that many of these people had lousy plans that actually covered very little — and that people who had them and became seriously ill ended up in bankruptcy. This is partly true. Some had purchased plans that essentially covered catastrophic care. But those plans no longer passed muster.
Second, the ACA originally set up pools of money called “risk mitigation corridors” to help insurers bridge the transition to the new system. Risk mitigation was designed to protect companies in the individual market that found themselves saddled with an unsustainable number of unhealthy people. Led by Sen. Marco Rubio, R-Fla., congressional conservatives targeted the risk mitigation money as “corporate welfare” and succeeded in decimating these payments. This led to insurers simply pulling out of the market, leaving the government in the untenable position of requiring Americans to purchase something they could not find for sale.
Third, the incentives to enforce the “mandate” were never aligned very well. In truth, Congress was uncomfortable passing a truly punitive penalty for those iconoclasts (or financially strapped millennials or small business owners with limited budgets) who felt the need to opt out. It’s a balancing act that the law hasn’t figured out how to finesse.
Others have different perceptions, but my point is that 17 days isn’t enough time to hash it out. It might take 17 months — or more. But the process can’t begin until the two parties start talking to each other. Practically speaking, that might necessitate a call from President Trump to House Democratic Leader Nancy Pelosi. In the meantime, a Republican administration is responsible for enforcing a troubled law it has bad-mouthed. This means that if the ACA falls — even if it falls on its own weight — Republicans will share the blame. The Freedom Caucus would be perfectly content with that result. I suspect voters going to the polls in 2018 would have other ideas.