As we saw back in 2009 with the Affordable Care Act, putting together a health reform bill that enough stakeholders support to pass through Congress is really, really difficult. Equally difficult however is putting together a heath reform bill that no one likes. Yet somehow in drafting the American Health Care Act, House Republican leaders have managed to write a bill that, as The Onion accurately put it, “has drawn criticism from the AARP, the American Medical Association, the American Cancer Society, Planned Parenthood, Breitbart News, the AFL-CIO, the House Freedom Caucus, the National Council of La Raza, the American Academy of Pediatrics, the Club for Growth, the National Disability Rights Network, MoveOn.org, The New York Times, Tea Party Patriots, the CATO Institute, the Heritage Foundation, and thousands of hospitals.”
It’s a bill that, according to the Congressional Budget Office, would add 24 million Americans to the ranks of the uninsured, raise premiums for the poor and elderly, raise deductibles and out-of-pocket costs for everyone else, and– thanks to its defunding of Planned Parenthood– would cause thousands of unintended pregnancies.
We’ll have more on what’s in the bill and what the CBO said about it later this week, but with so much health care news happening so quickly, it’s worth taking a step back to look at how Republicans managed to write a bill that– much like Nickelback— everyone seems to hate.
The Obama Years: Waiting for Go(p)dot
2009-2016: Repeal without replace. Since the passage of the Affordable Care Act, Congressional Republicans held over 60 different votes to either fully or partially repeal it. None of these votes included a replacement plan. Individual lawmakers and conservative think tanks had put forward plenty of replacement proposals— but none of them gained much traction, and there was never a push by Republican leaders to get behind any of them.
Spring of 2016: Trump’s “paroxysms.” All of the Republican presidential candidates called for the repeal of the Affordable Care, but were pretty hazy on what they’d replace it with. Donald Trump’s plan in particular was derided as a hot mess, with some of the harshest criticism coming from conservatives, like the Cato Institute’s Michael Cannon, who wrote:
This isn’t a health reform plan. It’s a campaign operative copying and pasting a bunch of stuff from the around the web, without knowing what it means or even realizing that he’s describing current law. It shows Trump is as unserious about reforming health care as ever. He doesn’t have a plan. He has paroxysms.
But as we wrote at the time, Trump may have biffed some of the details, but the basic format– a vague list of conservative ideas like selling insurance across state lines, promoting HSA’s, and block-granting Medicaid– was about as detailed as anything “serious” candidates like Marco Rubio or John Kasich put forward.
June 2016: A Better Way? Perhaps realizing that Congressional Republicans needed something they could call an Obamacare replacement before the election, Paul Ryan released A Better Way, which he called, “a first-time-in-six-years consensus by the Republicans in the House on what we replace Obamacare with.” As we wrote at the time, calling Ryan’s document a “plan” was a stretch:
The basics of any health reform plan are simple: (1) how much the government pays, (2) how much families pay and (3) what kind of coverage and services they get. The details can all get really complicated really quickly– for example, see the 1,000 page Affordable Care Act– but at the end of the day, all it’s describing is who pays what for what kind of coverage.
The document House Republicans released last week is missing all of that. It outlines the approach Republicans would take to reform the healthcare system, but we already knew that part: tax credits or deductions for coverage, health savings accounts, selling coverage across state lines, block-granting Medicaid, Medicare vouchers, high-risk pools, tort reform, etc. A plan would start to attach actual numbers to those ideas– for example, laying out how big the tax credits would be and how they’d be paid for. Instead, Ryan takes vague ideas that Republicans have been proposing for years and simply uses more words to describe them, apparently hoping we won’t notice that crucial details– the ones that an actual plan would include– are missing.
So for eight years the GOP kicked the can down the road by promising their replacement plan was just around the corner. Then in 2016, voters called their bluff.
The Trump era: Maybe we should have kept waiting…
November 2016: Tom Price as Health Secretary. Shortly after the election, President Trump released a hundred day plan for healthcare that was basically the same laundry list of vague proposals. However, he seemed to acknowledge he would eventually need an actual plan by nominating Tom Price as his director of Health and Human Services. As a Congressman, Price had put out his own plan, the Empowering Patients First Act, which laid out a similar approach to the GOP’s current replacement bill: eliminating the Medicaid expansion, high risk pools, and tax credits based on age. Along with Paul Ryan’s A Better Way Proposal (which also outlined a similar approach, just in less detail) it was likely used as a starting point for the AHCA.
January 2017: Republicans adopt a budget resolution to repeal Obamacare. Doing almost anything in the Senate requires 60 votes to overcome a filibuster– the one exception being “budget reconciliation,” which allows the Senate to pass a budget-related bill with a simple majority. The budget resolution passed by Republicans in January allows them to use reconciliation to repeal some parts of Obamacare (reconciliation can’t be used on non-budget provisions, like the rules against insurers charging more or denying coverage based on pre-existing conditions).
At the time, Republican leaders hoped to pursue a strategy of “repeal and delay,” in which they’d repeal Obamacare now, but would delay implementation of repeal until they came up with a replacement plan. That plan got nixed when health policy experts pointed out that the uncertainty alone could devastate the insurance market. As Vox’s Ezra Klein put it, “Repeal and delay takes something Republicans already can’t seem to do — agree on an Obamacare replacement — and weaponizes it against themselves.”
March 2017: Republicans in the House release the American Health Care Act. To get a sense of just how weird this process has been, it’s helpful to contrast it with how Congress passed the Affordable Care Act back in 2009:
- House Democrats held a series of public hearings on health reform from March until early May
- They then released a discussion draft proposal on June 19, then held more hearings in June and early July, before introducing an official bill on July 14.
- The CBO released a preliminary estimate of the bill’s budget effects, and it was sent to the relevant committees for markup.
- The finished bill finally came up for a floor vote in November.
At the time, Republicans complained that this process was “rushed.” Meanwhile, here’s how the process of passing the American Health Care Act has gone so far:
- The bill was written by House leaders in secret with no public hearings.
- Word got out that the bill was being kept under lock and key at an undisclosed location somewhere in the Capitol building for certain select members of Congress to read. Republican Senator Rand Paul grabbed a copy machine and went to the room where the bill was rumored to be held, but was denied entry by Capitol police.
- When the bill was finally released last Monday night, two simultaneous markups were scheduled less than 48 hours later. The bill passed out of the Ways and Means committee untouched at 4:30 a.m. last Thursday, after a marathon 17-hour markup session. This was less than 60 hours after the bill had been released, and before the CBO had a chance to score it.
- Republicans are hoping to get in on the floor of the House for a vote by next week, and get it passed in the Senate before the Easter recess.
It’s a little unclear why Republican leaders are moving at warp speed on this. The best explanation we’ve heard is that Republicans want to use reconciliation to pass both ACA repeal and tax reform this year, which, thanks to Senate reconciliation rules, requires a very tight legislative schedule. If they can’t get the AHCA passed in the next few months, that strategy could collapse (budget expert Stan Collender has a more in depth explanation here).
Another interesting theory that’s been floating around is that Republican leaders don’t actually want this bill to pass (or more accurately they don’t believe it can pass). Paul Ryan’s not dumb, and he surely knows that what Republicans have promised all these years– lower premiums and deductibles, with fewer regulations and lower taxes than Obamacare– is impossible. He also knows that any concessions he makes to the Tea Party make it more likely that more moderate Republicans in the Senate will kill it– and vice versa. The thinking might be that if they manage to get something through great; if not, they don’t want to waste much time on it.
With so much opposition, the AHCA is in “serious jeopardy“… but on the other hand we thought the same thing about Donald Trump and look what happened. In other words, if you’re worried about your healthcare, now might be a good time to call your Congressperson.