On Health Care, Republicans Are Only Negotiating With Themselves


From a certain perspective, the Republican effort to repeal (or at least rewrite) Obamacare made slow progress this week. The Freedom Caucus, one of the main sources of GOP opposition to the bill, endorsed an amended version. Republicans seem to have settled on state opt-out waivers, which, as Yuval Levin writes at National Review, could allow the party to navigate its internal political and policy differences. Key outside groups such as Heritage Action have dropped their strong objections to the bill.

And yet it's far from clear that the bill will actually move forward, because for all the progress Republicans appear to have made, the bill is still stalled. Despite multiple reports that the House would proceed with a vote on a bill to partially repeal Obamacare, another week has gone by with no actual vote. There has been no vote for the simple reason that the bill lacks the support to pass. Still.

For now, at least, the American Health Care Act (AHCA), remains dead. And if you want to understand why, it helps to compare the Republican effort to repeal Obamacare with the process by which Democrats put together the bill in the first place.

In some ways, the movement we have seen so far on the AHCA resembles the drawn-out process by which Democrats drew up and passed Obamacare in the first place. When Democrats put together the health care law in 2009, they were aiming to have the entire process completed by early or mid-summer. Instead, the process stretched out for more than a year, as holdouts negotiated tweaks and carve-outs. Then, as now, the process moved in in fits and starts, with various versions floated and then discarded, and congressional support levels hovering at some difficult-to-determine level below the threshold for passage.

But the GOP process this time around is distinct in at least one important way: Unlike Democrats, Republicans are only negotiating with themselves.

Democrats spent much of the summer of 2009 letting Senator Max Baucus, who oversaw the bill-writing process, negotiate with Senate Republicans, in hopes of picking up a veneer of bipartisan support. At the same time, the White House and Senate Democrats negotiated various deals with major players in the health care industry, including drug makers and trade groups representing hospitals and doctors. As a result of those deals, the industry groups helped sell the bill to both the general public and skeptical legislators, promising air cover in exchange for certain carve outs. Finally, President Obama used the bully pulpit to make the case for the law to both congress and the public. All of this followed years of discussions amongst liberal wonks and activist groups.

There was the usual internal wrangling as well, of course, with Democrats cutting deals with their members in exchange for support. But part of the reason that Democrats could make those deals was that they had gathered backers from other quarters, and had created a sense that passage was inevitable. External support created internal support. The process was self-reinforcing.

Republicans, in contrast, are negotiating entirely within their own congressional ranks—and really only within a small subset of House Republicans. The amendment released this week was written by Rep. Tom MacArthur (R-New Jersey), a leader of the moderate Tuesday Group, but it is designed almost entirely to appeal to members of the House Freedom Caucus. It's not clear that Senate Republicans want anything to do with this bill. "The Freedom Caucus has done a good job of trying to make the bill less bad," said Sen. Rand Paul (R-Kentucky) this week--not exactly a ringing endorsement.

And outside of Congress, there appears to be little or no effort at all. When the initial draft of the bill was released, conservative activist groups were widely opposed, and many complained that they had not been consulted at all. Health care industry groups, many of which oppose the current bill, have been left out of discussions entirely. ("[Republicans are] not interested in how health policy actually works," one insurance company official told The Los Angeles Times.) And President Trump has made no more than a cursory effort to sell the bill to the public; he has never delivered an extended speech devoted to the bill, and has never made any attempt to explain its virtues.

It's true that there are reasons—even some good reasons—why Republicans might want to avoid the sort of politicking and dealmaking that Democrats engaged in to sell Obamacare. Industry groups are likely to be hostile to many GOP aims, especially where reductions or shifts in government funding are concerned. Republicans are probably right to assume that, short of nationwide single-payer, there is no compromise measure that Democrats would join with Republicans to support. Trump, who does not appear to understand even the most basic policy elements of the GOP health care bill, is probably not the best messenger to make the public case that it improves on Obamacare.

But right now, no one is making that case. The Republican case for the AHCA rarely goes further than the declaration that it repeals Obamacare, which is bad. Many Republicans appear to believe that its main virtue is as a setup for tax reform.

The process by which Democrats sold Obamacare may have been long and unseemly, and may have resulted in an ungainly law that is often frustrating even to many of its supporters. But it also resulted in a bill that clearly advanced Democratic goals—and could pass.

One reason, of course, why Republicans are talking only to themselves about health care is that they had adamantly refused to do so during the Obama years. Despite promises to repeal and replace the health care law, the specifics were always to-be-determined. But so far, Republicans haven't even convinced themselves of what should be done. If anything, as Byron York writes, they seem to have decided that, contrary to what they promised, they did not really want to repeal Obamacare.

The GOP's failure to make the case for the AHCA to either the public or themselves is why the bill has an approval rating below 20 percent—far worse than even Obamacare, which was consistently unpopular under Obama. It's why there hasn't yet been a vote, and even if there is one, the bill, in its current form, still faces an uphill climb in the Senate. It's why even though we've seen signs of progress on the bill, we have yet to see the real thing.

And it's probably why the GOP's biggest achievement so far has been to finally push Obamacare into popularity, with poll after poll showing support for the health law on the rise. By not making the case for its current legislation—or, for that matter, any coherent alternative at all--Republicans have implicitly made the case for Obamacare instead.