Senate Republicans aren't saying much about what's in their health care bill, but they have made one thing perfectly clear: They have given up on fully repealing Obamacare. That is not an outsider's view. It is how Republicans themselves are framing the health care legislation that is now working its way through Congress. And it is one of the reasons why Republicans are continuing to struggle with the legislation now that it has been passed on the upper chamber.
Now that the American Health Care Act (AHCA) has passed in the House and moved to the Senate, Republican lawmakers are being blunt about the limited scope of the legislation they are considering.
The Senate, of course, is still working on drafting its own health care plan, which will reportedly differ from the House plan. No legislative language has yet been released, and few specifics have emerged. The policy and political challenges involved in crafting a bill are significant. And some Republicans are already tempering expectations by saying it won't be a full repeal of Obamacare.
"You can't repeal it in its entirety," Iowa Sen. Joni Ernst said this week. "You've got to have 60 votes and we don't have 60 votes at this point," said her Iowa GOP counterpart, Sen. Chuck Grassley. Instead, Ernst said, Republicans have the opportunity to "tinker around the edges."
These are statements about the limits of Senate procedure as much as it is one about the willingness of Republicans to eliminate the law entirely. The legislative filibuster effectively sets a 60 vote requirement to pass bills in the Senate. That's why Republicans hope to overhaul the health care law using a procedure known as reconciliation, which allows for legislation to pass on a simple majority vote. But legislation passed via reconciliation must meet certain conditions, including direct relevance to the budget, meaning that some of Obamacare's regulations are likely to remain in place no matter what.
But these statements also represent admissions that the years of GOP promises to repeal Obamacare will not be fulfilled. The procedural limitations are only one reason why. Party lawmakers have strong disagreements about how or whether to subsidize coverage in the individual market, about the role of Obamacare's Medicaid expansion, and about the necessity of maintaining the health law's preexisting conditions regulations.
At this point, then, the goal for Republicans is to rewrite the health care law rather than repeal it, which invariably means leaving in place many of its essential structural elements.
It is not clear, however, what sort of health policy improvements the GOP would actually accomplish through rewriting. The final Congressional Budget Office analysis of the AHCA found that it would result in 23 million fewer people covered a decade from now. That is the exact same coverage decline the CBO projected as under simple repeal. The initial version of the GOP actually covered even fewer people than a straightforward repeal, according to the CBO. Under all versions, premiums would rise sharply between now and the end of the decade, and would continue to rise afterwards, though less than under Obamacare.
Some of this may be attributed to the quirks of CBO's model, which probably overstates the effect of Obamacare's insurance mandate on coverage, and thereby exaggerates the effects of eliminating it. Even still, it suggests that the health law rewrites Republicans envision would do little to lower premiums or make coverage more accessible. Republicans would not be repealing Obamacare, in other words, and it's not clear that they would be improving on it either.
That helps explain why the bill now appears stalled in the Senate. Just last week, GOP Senate Majority Leader Mitch McConnell, who is usually businesslike in his optimism about the Republican ability to accomplish legislative goals, admitted that he did not know how Senate Republicans would put together the 50 votes necessary to achieve passage.
That doesn't necessarily mean that the bill will stall forever (although it might). The House version of the bill looked dead after a floor vote was called off. And House Republicans had their issues with that bill too. Days before the House voted to pass the American Health Care Act, Rep. Dave Brat, a Freedom Caucus member and Tea Party favorite who ousted Rep. Eric Cantor in a primary challenged, admitted that the AHCA was "not the repeal bill we wanted." Although Brat opposed an initial version of the legislation, he voted for its eventual passage.
But Brat's disappointment remains instructive. Given the limitations of the process, it's not too much of a stretch to say that the AHCA was not a bill that any Republican truly wanted. Nor, as McConnell's comments suggest, is it certain that such a bill could ever exist. Even if the Senate manages to pass something, it will still have to be negotiated with the House, creating more opportunities for disagreement. The only thing Republicans have agreed on about health care over the last eight years is that they want to repeal Obamacare, which they are now admitting they won't do.
Some Republicans, then, have started to figure out that they aren't going to fully repeal President Obama's health care law. But they still haven't figured out what they want to do—or why—instead.