On Obamacare, Republicans Achieved Nothing

Years of failure to establish a shared health policy vision led to last night's debacle.


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In the end, on Obamacare, Republicans accomplished nothing.

Not repeal. Not replace. Not even "skinny repeal"—the hastily constructed package eliminating a handful of discrete provisions from Obamacare that the Senate drafted, debated, and voted on last night. After seven years of promises to repeal and replace, the last-ditch measure failed by a single vote, thanks to a trio of GOP senators, including John McCain, who were worried that if it passed it might actually become law, an outcome that few if any Republicans desired. The health care law will live on, for now.

Last night's legislative denouement mostly served to demonstrate how desperate and confused Republicans are when it comes to health care: Senate Republicans could not come up with any health care legislation that they wanted to pass, so their final push revolved around a plan to vote for legislation that they very much did not want to pass.

Let that sink in for a moment: The final Republican health care plan was to pass legislation that they did not want to become law.

The goal, instead, was to use the skinny repeal bill as a vehicle to move on a conference negotiation with the House, in hopes that some sort of common ground could be found between the two chambers. How exactly this was supposed to succeed where previous efforts failed was never clear. Senate Republicans couldn't come up with a bill on their own; why would adding the House, which is divided by factionalism and internal disagreement, make the process any easier?

It's not just that Republicans didn't have a plan. They didn't even have a plan to come up with a plan.

Part of the problem was a lack of policy leadership. President Trump does not appear to grasp the most basic elements of health care policy, or care about the details of the legislation he signs. He wanted a political win, not policy progress.

And Senate Majority Leader Mitch McConnell wanted to give it to him. McConnell is an effective congressional tactician who understands the legislative process and the pressure points it creates. But he is not a policy visionary, and the evolution of the Senate plans—from repeal and replace to clean repeal to skinny repeal—shows the limits of tactics without strategy.

For the last decade or so, Paul Ryan has served as the party's most prominent policy entrepreneur. But the further he has risen in the party's official ranks, the less effective he has become. Now, as speaker of the House, his main job is to corral the party's many confused and warring factions rather than to make the case for the bigger picture and legislation to support it. The tumult of the Trump presidency has only made this job more difficult.

So even the more detailed legislative plans that the House passed and the Senate published were little more than plans to scale back Obamacare but continue working within its essential framework.

The outcome, splayed out in the news for all to see over the last several months, was that when the party gained power and it finally came time to legislate, debate, and vote, Republicans had no shared vision, and thus no workable plans to achieve it.

The result, in other words, was total failure: to live up to the party's most persistent political promise, to advance the nation's health care policy in meaningful ways, or even to achieve a narrow "win" and move on to something else.

The push to repeal Obamacare may—may—now be over. But health care policy is not going away. Half of the nation's health care spending, give or take, flows through the federal government. The exchanges set up under the health care law are still struggling, and premiums are still rising. Many doctors still reject or limit access for Medicaid beneficiaries, and Medicare is the single largest driver of the nation's long-term budget problems. The good news, which is also the bad news, is that there will be plenty of time and opportunities to address the nation's health care problems in the future.

What Republicans—and Democrats and independents and anyone else interested in a health care system that is more fair, more effective, and less expensive—need to do, then, is what they have largely failed to do for so many years: Start from the ground up, think comprehensively about the health system as a whole, develop a vision, and then debate and defend plans and policies that would bring us closer to it.

Earlier this month in The New York Times, I outlined what such a vision might look like: encouraging supply-side innovations, emphasizing cost reductions instead of subsidies, seeding the idea that insurance is financial protection rather than health care, emphasizing aid to the poor and needy rather than comprehensive universal coverage, focusing on eliminating fragmentation and favoritism in a system that for decades has been defined by it.

This is the health policy long game that Republicans have never bothered to play—and that Democrats who support a larger role for government already are. Single payer, price controls, and more expansive government systems of all kinds are already in the works, especially at the state level. Republicans and others who want to limit the role of government in health care have a lot of catching up to do.

As I wrote in that piece, it won't be quick or easy. But as Republicans have now discovered in such a public and embarrassing fashion, it never is.