On Wednesday, the House passed a bill that would repeal most of the Affordable Care Act’s key provisions. It’s the same bill that the Senate passed in December, which means the measure now goes to the White House -- where its journey will end, because President Barack Obama has already promised to veto it.
This is not a surprise. There’s zero chance Obama would sign a bill wiping out his signature domestic policy achievement, which means there’s zero chance Obamacare repeal would happen while he’s still in office.
Does that make the whole exercise pointless?
HuffPost’s Jeffrey Young thinks so. His colleague Jonathan Cohn isn’t so sure. The two were debating it over gchat this morning. Here’s a transcript of their conversation, lightly edited for clarity:
Jeffrey: As I wrote in HuffPost Wednesday, this is the conclusion of a very long road to nowhere, not least because congressional Republicans have proven themselves incapable of producing a consensus plan that represents their vision for the health care system, and merely doing away with Obamacare isn't a practical goal in and of itself.
Jonathan: I don't know, this vote feels different from the previous ones. It’s the first time that a repeal bill went through the Senate, which means the leadership there had to work through some of the basic questions and trade-offs of repeal, and make the necessary political calculations for getting a bill through.
And because they were using the reconciliation process, in order to avoid the inevitable Democratic filibuster, they had to figure out what they could and couldn’t include in a bill under the special rules for that kind of vote. That meant meeting with the Senate Parliamentarian, who's the arbiter of such issues.
You can't repeal and replace without replace, and you can't just repeal ... I believe Mitch McConnell and Paul Ryan know this. Jeffrey Young, Huffington Post
Just the process of having all of these conversations -- figuring out what's kosher with the parliamentarian, getting Congressional Budget Office scores, and so on -- puts them in a better position to act come 2017, should they have the opportunity. They’ll be able to say, "OK, we know that reconciliation limits us to certain provisions, we have a better sense of what our caucus does and doesn’t consider important, etc." That would make it easier to pass a bill.
Jeffrey: There’s no bill to pass! Do you really think the Republican Party is suddenly eager and comfortable with making policy in this area -- about their willingness to, say, kick a bunch of people off their insurance and acknowledge that their promises are impossible? In opposing Obamacare, the GOP has repeatedly vowed that they can make health insurance better than it is under Obamacare and better than it was before Obamacare, while not spending very much money or imposing new federal regulations. If it were that easy, they would have done it before, like when George W. Bush was president and Republicans controlled Congress.
Jonathan: You’ll get no argument from me on that last point. If Republicans had a better, cheaper way to provide the same kinds of benefits and protections, they’d have proposed and passed it long ago.
I also agree that Republicans would be a lot more skittish about voting for reform if such a bill had a chance of becoming law -- and taking away insurance from so many people. We’ve seen that recently in Kentucky, as you’ve written, where newly elected Gov. Matt Bevin (R) has backed way off his promises to opt out of the ACA’s Medicaid expansion.
But there’s a lot of extremism out there -- in the tea party wing, in the candidacies of Donald Trump and Ted Cruz, etc. I just don’t feel confident they’d back off. They’d try something. And it could be substantial.
Jeffrey: But what is the aim? What's the goal? What's the bill? They would do all of what you've described in service of what?
Jonathan: If Republicans come out of 2016 with control of the White House and Congress, the base is going to demand action on Obamacare. Congress will have to do something. It's a question of how little they can do while making it look like they're doing a lot.
I could totally imagine Republicans passing a package that includes some combination of the following: (1) block granting Medicaid, (2) significantly reducing regulations on insurance, (3) handing more regulatory authority over to the states, (4) significantly reducing what the government spends on subsidies.
That would affect a lot of people negatively -- very, very negatively. But Republicans would do their best to disguise that fact, while playing up features like lower premiums for young, healthy people. They might also try to phase in the changes slowly, by disallowing new enrollment while letting the people who have coverage keep it -- even though, as we both know, that can’t really work.
Jeffrey: But then they still have to answer for the consequences of that, and I don't think they want to. And no one can fill in this blank: "We control the White House and Congress, which means we can now ______ in health care." You can't repeal and replace without replace, and you can't just repeal, no matter what #tcot thinks. I believe Mitch McConnell and Paul Ryan know this.
I think their base being furious (or rather, continuing to be) is a given, because those voters have been promised things the party cannot deliver. They can't just wipe away the ACA, they can't revoke everything Obama has done, they can't beat ISIS in a week, etc. That's going to be the overarching story if there's a Republican president.
They’d have to pass something. The question is whether it would go beyond cosmetics. Jonathan Cohn, Huffington Post
The chickens could come home to roost. When you've hyped a million terrible problems and scared people into believing them, you're stuck. The problems were fake or exaggerated, so how can you solve them? And there simply aren't enough people who hate Obamacare so much they'd be totally happy screwing over millions and millions of people.
No one is carrying pitchforks to Matt Bevin's house about how he needs to kick all those people off Medicaid. It's like I (and you) have been arguing for a long time: Talking about repealing the hated Obamacare is good politics. Actually repealing Obamacare doesn't seem to be.
Jonathan: Correct. But at least in the last few years, Republicans have been known to do some pretty stupid things politically, like shutting down the government. Plus, you know, they might end up nominating Trump or Cruz.
Jeffrey: Government shutdowns are temporary, and primary voters aren't the same as legislators. Nobody in Washington likes Trump or Cruz, and they don't seem like the types who are eager to hunker down with GOP lawmakers and develop compromises.
Jonathan: Right -- but Republican primary voters might saddle the party with one of those guys anyway. (I’m betting Cruz.)
Jeffrey: And they won't be able to govern at all -- and especially not pass contentious health policy that requires rejiggering the winners and losers in the health care system -- because Trump and Cruz aren't political dealmakers, and GOP leaders in Congress aren't going to just do whatever they want.
Look at King v. Burwell. They had this "opportunity" to use that to their advantage, if actually repealing and replacing Obamacare was their true goal, and all they came up with was postponing repealing it so they could postpone replacing it because they have no fleshed-out ideas about how to fulfill their promises without looking cruel to the people whose insurance they'd take away.
Collectively, these politicians don't know what they want, so how can they pass anything? And if they ever got close to actually just wiping out the ACA, it wouldn't just be bleeding-heart liberals screaming bloody murder. The health care industry -- including insurers and hospitals and doctors -- would be deeply scared of the disruption, and would make their views known to lawmakers and the public.
Even those in the system who don't like the ACA are already adapting to it, and already went through the disruption of 2010-2014, so they won't be in a hurry to do it again. Maybe diehard tea party people won't care about that, but most people aren't that engaged, and most people don't actually want to fully repeal the law anyway, even though most people view it unfavorably.
Jonathan: Sure. But, like I said, they’d have to pass something. The question is whether it would go beyond cosmetics. There's a pretty big middle ground between tinkering and wiping away the law in its entirety.
For example, would there be an uproar about block granting Medicaid and cutting funds over time? The effects would be devastating. And Bill Clinton beat Newt Gingrich over that very issue, I know. But the GOP seems crazier now. The hospital industry has begged conservative state officials to expand Medicaid, but plenty of states, including Florida and Texas, still haven’t. Similarly, insurance company protests didn’t stop the GOP Congress from cutting the law’s “risk corridor” funding.
Jeffrey: Yes, I think there’d be an uproar -- because every block grant proposal is just a massive funding cut is disguise, and it's very easy to point that out to people: "The Republican Congress wants to take away health care from XX million of the poorest and most vulnerable Americans."
Jonathan: And Republicans will respond by saying, "No, we just want to give states more control and -- at the same time -- give middle class Americans a tax cut." Maybe their gambit fails, but maybe it doesn’t.
Jeffrey: They say that about everything, and they rarely enact any of it into law.
Jonathan: Yeah, that’s a good point. Even when Republicans had unified control during the early Bush years, they put their energy into cutting taxes -- not cutting spending or eliminating programs. (In fact, as we both know, they ended up increasing spending massively with that Medicare prescription drug bill.)
I guess I just worry that, this time, things will be different. I mean, if we’re in a world where Trump or Cruz could become the nominee -- and then become president -- who’s to say what is and isn’t possible?
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