Republicans Can't Gut ObamaCare Without Gutting Selves First

Donald Trump let slip something that, by his low standards, almost passes for truth when he said Monday that "nobody knew healthcare could be so complicated." It's not, strictly speaking, true. Democrats in Congress and the White House, who engineered the Affordable Care Act's passage without any Republican support, knew it was a complicated issue. The difficulty Republicans are having even proposing a replacement can attest to their diligence. But the average American didn't understand the finer points of health policy, Republicans took advantage of that by blaming anything they could on Obamacare, and now their chickens are coming home to roost.

Republicans voted over 50 times during the Obama administration to repeal some portion of the Affordable Care Act, so one might think that, over the course of the last seven years, they would have been able to generate some kind of concrete plan as a replacement. But one would be very, very wrong. When it comes to replacing Obamacare, the Republican party is caught between a rock and a hard place. The rock is the conservative orthodoxy that the government shouldn't expand entitlements or get involved in private enterprise. The hard place is the reality that people in the richest nation on earth don't want to die or be forced into bankruptcy because of health emergencies.

Let's start with conservative orthodoxy. While some of the Republican replacement plan is still literally a placeholder, conservative groups like the Republican Study Committee and the Freedom Caucus have already attacked the draft as new entitlement spending for its provision to grant refundable tax credits for health insurance. That provision exists under Obamacare, but is offered on a sliding scale based on your income. Which is to say, the current battle within the Republican conference is whether to eliminate tax credits as assistance in paying for health insurance or to make that assistance available to wealthier people. That's not a good look for a Republican party hoping to hold on to the working class voters Donald Trump attracted, so expect it to happen off-stage. If these fringe groups get their way and eliminate all tax credits for healthcare, expect costs to sore, Americans to lose insurance, and an even angrier electorate in 2018 and 2020.

Which brings us to reality: Obamacare is more popular than ever, both among Democrats and independents. Perhaps that's because more and more Americans are slowly realizing that the Affordable Care Act that they've loved for the last seven years actually is the same thing as Obamacare. Maybe it's because in Governor Steve Beshear's Kentucky, the uninsured rate was slashed from 20% to 7.5%, which apparently qualifies as a "disaster" in the eyes of his successor.

I wouldn't call Obamacare an unmitigated success, and I don't think Barack Obama himself would say that it is. Even after its passage, healthcare remained the leading cause of bankruptcy in the United States. As Margot Sanger-Katz put it for the New York Times, "Here is the surest way to enjoy the peace of mind that comes with having health insurance: Don't get sick." We have the most expensive and lowest quality healthcare out of the eleven richest countries in the world, in part because reform efforts have focused more on getting people covered and less on driving down costs or improving services. This is the difference between access on paper and access in reality; most people would prefer it in reality. And while Americans suffer under increased costs for care and prescription drugs, the pharmaceutical industry is seeing its profit margins balloon to levels as high as 42%.

These are the realities that made Obamacare an easy punching bag for the last seven years. And so long as Barack Obama was in the White House, the Republican Congress could keep on punching, passing all the legislation it wanted and knowing that their regressive and unpopular measures would never be signed into law. But those days are over. President Trump will sign what they pass, and that's been an obstacle to actually passing anything. With one half of their conference pushing to do less and the other half pushing to do the same but less progressively, they've been backed into a corner where the Democrats can finally do battle on their home turf. Expanding government assistance for healthcare and increasing regulation on insurance companies and pharmaceuticals is a political winner among the working class (as evidenced by Donald Trump impossibly and inexplicably promising universal coverage).

Donald Trump's election was interpreted as the death knell for Barack Obama's healthcare agenda, but the Republican efforts since have suggested otherwise. So far, there is no bill the Republicans can pass that won't make the American electorate long for the halcyon days of Obamacare. While the battle of 2016 was a disaster in the push to expand access to healthcare, the tide of the war appears to be turning.

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