Repeal and Replace, R.I.P.

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Oh, if only the House Speaker hadn’t tried to push through health insurance legislation so quickly, without enough consultation and deliberation. If only the Freedom Caucus had shown a little more flexibility. If only President Trump had sold the bill more effectively, actually understanding and explaining it instead of just declaring it wonderful. Then maybe the outcome would have been different.

Or maybe not. This week’s health care debacle was not just a tactical failure; it was a colossal policy failure. After seven years of riding a wave of popular discontent with Obamacare, Republican leaders presented their alternative, and it promptly bombed. Once the Congressional Budget Office projected how many Americans would be worse off under the plan, popular support for it fell to 17%. What they have probably succeeded in doing is making Obamacare more popular, now that people see how hard it is to improve on it.

The fundamental problem was that “repeal and replace” wasn’t really a very good idea. Although Obamacare did force some people to buy policies for more than they wanted to pay, it helped a larger number buy the insurance they needed. As the number of beneficiaries grew, so did resistance to a simple repeal. Republicans had to claim that they had something better with which to replace the law, and Donald Trump made that claim a centerpiece of his campaign. Trouble is, they never did come up with adequate replacements for the provisions of Obamacare they wanted to get rid of. They were never going to replace the hundreds of millions of dollars of revenue they would lose by eliminating the Obamacare taxes; nor were they going to replace over a trillion dollars of insurance subsidies and Medicaid benefits they wanted to cut. The tax credits they offered were better than nothing, but not as good as the  benefits available to most beneficiaries of the existing law. Lower-income, older and rural folks were going to be hurt the worst, making the bill worse for Trump supporters than Clinton supporters.

As a result, the legislation had little appeal. It wasn’t the total repeal that the far right wanted, but it took away too much to please Republican moderates, such as governors whose states benefited from the Medicaid expansion. Democratic support for the bill was practically nonexistent.

For Trump, the defeat on health care represented a massive failure to live up to expectations. After repeatedly promising to make health insurance more affordable for more people, he threw his support behind a bill that did no such thing. He did not demonstrate that he knew or cared exactly what was in the bill, as long as he could undo the Obama administration’s principal domestic achievement. He was even willing to trade away the essential benefits insurance policies must now cover, such as maternity care, in order to pick up a few more votes. In the end, his legendary deal-making skills were no match for a divided Republican Party. Now he tries to make the best of it by rooting for Obamacare to fail, so that the country can blame the Democrats and adopt a Republican alternative, no matter how flawed. Trump even claims that this was his preferred strategy all along. But he got elected by running on “repeal and replace,” not “sit back and let fail.” That’s not the leadership people hoped for. Even worse, the administration may try to sabotage Obamacare by finding ways to discourage people from signing up or insurance companies from participating. That wouldn’t be leadership either, and it would violate the President’s oath to faithfully execute the laws.

The more responsible strategy would now be “retain and repair.” Bring together some reasonable leaders of both parties to identify the weaknesses in the Affordable Care Act and address them specifically. Find some ways to control premiums and deductibles, but don’t fix things that aren’t broken, like the Medicaid expansion.

Somewhat belatedly, Trump has discovered that health care is hard. Maybe we are making it too hard by trying to add in too much profit for insurance companies, on top of the high cost of medical treatment itself. Eventually the US may have to follow other developed countries by insuring everyone through a single-payer, government-run, non-profit system. Premiums could be lower; benefits could be standardized; and people could buy supplemental insurance if they chose, as many do with Medicare. If that’s the direction we ultimately go, then “repeal and replace” may come back to life, but not in a form that conservatives will recognize.



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