Alex Wadden and Daniel Béland

Repealing the Affordable Care Act (ACA), which is also known as Obamacare, had been a mantra of Republicans ever since its passage in March 2010. The Tea Party drew much of its energy from its opposition to the ACA and Republican candidates had reiterated their commitment to undoing the law in each subsequent election cycle. This paid dividends for the party in the 2010 mid-term elections, but the re-election of President Obama in 2012 seemed to ensure that the ACA would continue its rollout, which was always scheduled to be a prolonged process, as he would be able to block efforts by congressional Republicans to repeal the law. Nevertheless, continuing, and effective, Republican opposition to the ACA was illustrated by efforts to obstruct implementation at the state level; for example, at the start of 2017, 19 states still refused extra federal funding to expand their Medicaid programmes to cover low-income, uninsured Americans. This level of resistance to Medicaid expansion, which generally occurs in Republican-controlled states, was made possible by a June 2012 Supreme Court decision that upheld most components of the ACA but forbid the federal government to punish states that refused to expand the programme. Furthermore, in January 2016, Obama was forced to use the presidential veto to block a bill passed by the Republican controlled chambers of Congress that would have repealed large parts of the ACA.

The 2016 presidential election cycle demonstrated once again that promising to “repeal Obamacare” was catnip to Republican candidates and the party’s base. And, although candidate Trump did break with some aspects of conservative orthodoxy when promising that he would not cut the Medicare or Social Security programmes, he was fully onboard with the anti-ACA rhetoric. Thus, Trump’s unexpected victory in November 2016 meant that Republicans, enjoying unified government in Washington DC as they now controlled the White House and both the House and the Senate, could now fulfill their longstanding promise. Doing so, however, turned out to be much more complicated than anticipated.

In early May 2017, the House of Representatives passed the American Health Care Act. This occurred after an abbreviated, yet still tortuous, process, with the initial proposals withdrawn from consideration ahead of a floor vote due to opposition from all Democrats, but more decisively by moderate Republicans and conservative members of the House Freedom Caucus. Eventually the last group were satisfied by changes to the bill meaning that the AHCA garnered sufficient support to pass the House. That was followed by a rather presumptive White House ceremony, of the sort normally reserved for when a President actually gets to sign a bill passed by both House and Senate. Expectations were high that such a moment would come, but ominously for Republicans, while AHCA did repeal important parts of the ACA, few thought that it was a coherent model for reform and the hope was that Senate would put together a more comprehensible package.

Republican Senate leaders, in their desire to craft a bill quickly, chose to bypass so-called “regular order”, thereby significantly truncating the legislative process and relying on a Republican only taskforce to develop a bill. They also chose to push the bill through the “reconciliation” process, thus negating the possibility of a filibuster, meaning that they would need only 50 votes since they could rely on the casting vote of Vice President Pence. Yet, even after tilting the playing field, Senate Majority Leader Mitch McConnell of Kentucky, renowned for his party management, could not muster enough votes. The final blow came when, in late July 2017, the Senate voted down so-called “skinny repeal”. Few thought this a satisfactory way forward, but it was advanced by the leadership on the same, kicking the can down the road, logic used to justify the passage of the AHCA in the House. Only this time a House – Senate Conference Committee was expected to come up with a coherent plan to save the day. In the end, just over six months into Trump’s presidency, the Senate repeal effort failed.

Although the debate on the future of the ACA is by no means over, this recent failure leads to an obvious question: why, after seven years of deriding Obamacare, were Republicans unable to undo the law when in an institutional position to do so? A cynic might suggest that they never expected to have to fulfill their promise, especially as the 2016 campaign unfolded and the prospect of a Trump presidency seemed remote, leaving them confounded when faced with delivering on their rhetoric. Yet, there were plans in the conservative eco-system on how to move forward on health care reform, so unpreparedness is not a sufficient explanation. It is the case, however, that the party had never come together over any particular plan, reflecting how the US health care system is extraordinarily complex, a fact that President Trump discovered, apparently to his, though no-one else’s, surprise.

In this context, while the ACA was consistently underwater in polling during Obama’s presidency, the law did have features that were popular, and Republican lawmakers struggled with crafting plans that would keep those legacies in place, but simultaneously repeal other parts of the ACA that effectively supported them. In particular, Republicans committed themselves to maintaining the ACA’s principle that individuals with pre-existing conditions should have access to affordable health insurance. The reality that this principle required spreading the cost of risk to healthy people, however, proved problematic when Republicans were also promising to reduce the insurance premiums for the healthy. More generally, as the ACA had been implemented, the numbers of uninsured Americans had dropped considerably. The manner in which that drop was largely attributable to the ACA became ever more apparent as each of the Republican plans put forward in Congress were scored by the non-partisan Congressional Budget Office as likely to leave over 20 million more Americans uninsured.

Furthermore, it is important to acknowledge the ever present difficulty of getting any major reform through the US legislative maze, even when one party controls both Congress and occupies the White House. In 2017, the Republicans stumbled in the Senate where they had only a 52–48 majority. McConnell made no effort to reach out to Democrats, which put a premium on his ability to corral his caucus. Yet, while the well-documented trend of partisan polarization in the US had seen the Republicans become a considerably more conservative force, there turned out to remain some moderate Republican voices in Congress worried about the consequences of taking insurance away from millions of Americans. On the final vote on skinny repeal, most of the attention focused on Senator John McCain from Arizona, returning to the Senate after a diagnosis of a severe form of brain cancer, and his vote against. In fact, the more consistent voices of opposition to the leadership had come from Senators Susan Collins of Maine and Lisa Murkowski of Alaska.

Finally, it is worth reflecting on the role of President Trump. He had promised prompt repeal of the ACA upon taking office, and his frustration was clear in the summer as he lashed out as the congressional efforts stalled, including a side swipe at McCain in an extraordinary August 15 impromptu press conference on the recent violence in Charlottesville, Virginia, during which he apparently equated Nazis and KKK supporters with those protesting against them. Yet for all the presidential bluster, it was very clear that Trump had minimal grasp of the policy detail, which undermined his capacity to make a public case for why Republican plans for reform were a good idea and diminished his ability to sway the likes of Collins and Murkowski.

From a Republican perspective, one distinctly unintended consequence of their actions was to boost the popularity of the ACA. Yet, supporters of the ACA should remain wary. First, the Republican reform effort may look like the walking dead, but zombies can do harm to the living. To switch monster analogies, it maybe that Republicans try again to build a Frankenstein repeal bill if they make the calculation that it is more politically damaging to break their seven year promise than to enact something that might be very unpopular. Second, the ACA, particularly with regard to functioning of the individual insurance markets, needs the federal and state governments to take a pro-active role in encouraging households to enroll and pressuring insurers to offer plans where returns are likely to be low. Trump has regularly declared that he is happy for the ACA to implode and for Democrats to take the blame. As it is, he is likely both underestimating the resilience of the law and misjudging the political fall-out should people become even more disgruntled with their health care. But politics, bravado, and bluster aside, the administration does have the capacity to undermine the implementation of the law and leave many more Americans exposed to both economic and health risk should they need medical care.

 

Daniel Béland is Professor and Canada Research Chair in Public Policy at the Johnson-Shoyama Graduate School of Public Policy, University of Saskatchewan. Alex Waddan is an Associate Professor in American politics at the University of Leicester.

Image: Fibonacci Blue CC BY 2.0