The Death of the Republican Health Care Bill: A Post-Mortem Analysis

Last Friday, House Speaker Paul Ryan withdrew his health care bill from consideration after it became clear that he had failed to amass the support necessary to get it passed. It was a victory for Democrats, for the 14 million people who stood to lose their health insurance next year if the bill had gone through, for the hospitals and community health centers that would have lost revenue when their patient base dwindled or was less able to pay for care, and for the countless Americans who depend on mental health coverage, drug treatment, maternity care, preventive services, and other essential health benefits mandated by the Affordable Care Act.

It was a major defeat for Ryan, for Trump, and for the Republican Party, which now faces a tougher battle to enact the rest of its agenda. In particular, the massive, permanent tax cuts for the rich that Ryan has been eager to pass now look less likely. The reasons why have to do with the nitty-gritty of the legislative process, but my understanding is that it goes something like this: in order to get around a potential Democratic filibuster, any GOP tax bill would have to be revenue-neutral after ten years, meaning that it could not increase the federal deficit after that point. The GOP needed to repeal the ACA and its $1.2 trillion of taxes on higher-income earners first to reduce the baseline of tax revenue. This would then have allowed them to design a tax code that could bring in $1.2 trillion less and still be revenue-neutral. (Jonathan Chait at New York Magazine has a more detailed explanation here.) But since the ACA repeal failed, the Republicans will have to rethink their strategy on tax cuts and what’s politically viable right now.

The larger takeaways from the downfall of the GOP’s American Health Care Act have to do with what it reveals about the current political moment and what comes next.

1. The Republican failure to repeal Obamacare indicates a federal right to health care that now cannot be taken away. A number of commentators and lawmakers have said this, including Chait (again) in a column last Friday, Jonathan Cohn in the Huffington Post, and Senator Bill Cassidy (R-LA) in an article in the New York Times. I hope they’re right, but I’m more cautious. The AHCA died not because moderate Republicans decried the bill’s cruelty in stripping away health insurance from their constituents. Rather, it was defeated by a coalition of Republicans with a range of political convictions. According to an analysis in the New York Times, nearly as many ultra-conservatives (15) were against the bill as moderates (10) and “others” (8) combined. The hard-liners thought the legislation didn’t go far enough in ending the ACA and its protections, among them Medicaid and the law’s essential health benefits. In short, there was no ideological consensus among the Republicans who were opposed to the bill.

2. The AHCA revealed the GOP’s true aims: tax cuts for the wealthy and cuts in benefits to low-income Americans. As I’ve written previously, the bill was stunning in its barefaced cruelty, gutting Medicaid and reducing income-based subsidies to pay for health insurance, while pushing through enormous tax cuts for rich people.

3. Politics, not policy, dictated the process. As the last-minute deal-making revealed, there is no GOP agreement on the federal government’s role in providing health care to its citizens, or even whether it should. The AHCA was driven by a political directive to pass a bill so that Republicans could say they made good on a campaign promise, with little regard for how people would be affected. The Congressional Budget Office’s estimate that 24 million Americans would lose their health insurance within a decade was twisted into an avowal that once people were freed from the shackles of government interference, they would have the ability to choose a plan that worked for them and their health care needs. Trump’s statement on Friday that the best thing for the Republicans politically would be to let Obamacare “explode” indicates his lack of interest in the actual lives of people who are affected by what the government, of which he is now in charge, does and does not do.

4. There are still plenty of ways for Trump and his administration to weaken the Affordable Care Act.  They could rewrite regulations to undo some of the act’s provisions, including no-cost contraceptive coverage and the cost-sharing subsidies that help people pay for co-pays and deductibles; both of these were added to the ACA by rule and are not written into the law itself. Or they could undermine the exchanges by pulling funding for advertisements in advance of the open enrollment periods, which could lead to fewer people signing up.

In short, the Affordable Care Act may be safe for now, but this is just the beginning. And whether the law is weakened or strengthened through the tweaks that are sure to come may depend on continued public pressure to expose the ways in which the law is working, as well as the ways in which it can be improved.