White House meeting on health care, March 10, 2017.
Photo courtesy the Executive Office of the President of the United States.
Everyone knows that Rome was not built in a day, as the saying goes. It was not destroyed quickly, either; depending on which historian you consult, the fall of the Roman empire took place over anything from a couple hundred years to more than a millennium.
Critics of the Affordable Care Act – and maybe even some of its more ardent supporters – may want to keep this fun fact in mind as they size up the meaning of last week’s epic fail in the first serious effort to repeal and replace Obamacare.
While Democrats remained unified in their opposition to any proposal that included the words “repeal” or “replace” in connection with their signature achievement of this decade, Republicans fractured. Conservatives said their leadership’s proposal did not go far enough. Moderates – meaning anyone running in a district carried by Hillary Clinton in November – said it went too far in potentially eliminating coverage for a projected 24 million individuals (consisting mainly of single adult Medicaid recipients and private purchasers who are expected to drop coverage voluntarily if the law’s mandate is repealed).
In the end, House GOP leaders pulled their bill rather than face what seemed like inevitable defeat in a floor vote. President Donald Trump, who had lobbied hard for the legislation, was widely portrayed as having been the biggest loser, although in the end a president can only sign the bills that Congress places on his or her desk.
House Speaker Paul Ryan predicted that the vote will mean Obamacare survives “for the foreseeable future.” Many other observers forecast that the next big objective for congressional Republicans – tax reform – is in similar danger of failing as they struggle to achieve consensus and achieve some legislative victories.
Maybe so. Maybe Republicans will prove once again, as they did in failing to gain control of the Senate in 2010 and 2012 despite good odds, that they know how to achieve defeat in the face of near-certain victory. Maybe opposition for its own sake actually is the ultimate motivator for the House Freedom Caucus and like-minded senators, such as Ted Cruz of Texas and Rand Paul of Kentucky. But not necessarily.
I would bet that even as you read this column, key administration officials including Vice President Mike Pence and Health and Human Services Secretary Tom Price are quietly working the Capitol’s hallways and phone lines, laying the groundwork for another run at the Affordable Care Act. It won’t happen right away. They will wait for lawmakers to get deeper into the weeds of tax reform, which is when last week’s recalcitrant conservatives (and their campaign donors) will discover that without the projected $1 trillion in budget savings that Ryan’s bill would have produced, it will be much harder to get their favorite tax-cut plans enacted.
As summer simmers into autumn, Americans will also witness yet another round of insurance companies leaving the Affordable Care Act’s private marketplace in droves, while those that remain file for another helping of hefty rate increases to cover the cost of the increasingly self-selected sick and old purchasers taking advantage of the law’s flaws and loopholes. Now that we have an administration that is unwilling to paper over these problems, the Affordable Care Act’s underlying economics are shakier than ever. Backers of repeal will remind everyone that they told us so, while those who opposed Ryan’s bill will be under the gun to come up with their own answers.
Most high-wattage legislation takes years to enact. While public debates rage over broader policy goals and the tactics proposed to achieve them, private discussions take place to assemble winning coalitions. In the past those have tended to cross party lines; nowadays, at least for taxes and health insurance matters, such bipartisanship may be impossible. But Republicans are at least mathematically capable of assembling their own internal coalition as long as they hold majorities in both houses of Congress plus the White House. As time passes, pressure will mount on the GOP side not to let this opportunity go to waste.
So the saga of health care reform rolls on. It will take significantly more time to determine whether last week marked a successful defense of the Democrats’ citadel, or just the initial battle in what may turn out to be a long siege.