"If the Republican Party’s crusade to repeal and replace the Affordable Care Act is truly over, Monday night provided a fittingly sudden and chaotic ending. Early in the evening, two conservative Republican senators—Mike Lee, of Utah, and Jerry Moran, of Kansas—issued statements saying that they wouldn’t support the revised health-care-reform bill that Mitch McConnell, the Senate Majority Leader, released last Thursday. Since the Republicans have a majority of just two in the Senate, and two other Republicans—Susan Collins, of Maine, and Rand Paul, of Kentucky—had already announced that they wouldn’t vote for the legislation, the effort to secure its passage looked lost.
For several hours after Lee and Moran’s announcements, McConnell issued no public response. Then, around 11 P.M., he released a statement that said, “Regretfully, it’s now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful.”
But McConnell didn’t leave it at that. Instead, he said that the Senate Republicans would now move to vote on repealing the A.C.A. immediately and dealing with the consequences later. Since those consequences would include causing turmoil in the private markets and reversing the Medicaid expansion that has provided health-insurance coverage to about fourteen million Americans, it seems very unlikely that McConnell will be able to get fifty votes to pass such an irresponsible piece of legislation.
It wasn’t immediately clear whether McConnell really believes such a reckless strategy is feasible, or whether he was simply looking to save face. President Trump, however, supports pursuing repeal without replacement. On Monday night, he tweeted, “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!” That final sentence was almost certainly wishful thinking. And the entire statement was consistent with the lack of gravity, inattention to detail, and political gamesmanship that has characterized the Republican effort to undo Obamacare since the beginning.
The larger lesson of this sorry episode is that nobody—not McConnell, or Trump, or House Speaker Paul Ryan—can resolve the contradictions of today’s Republican Party. Once the political arm of the Rotary Club and the affluent suburbs, the Party is increasingly one of middle-class and working-class voters, many of whom are big beneficiaries of federal programs, such as Medicaid and the Obamacare subsidies for the purchase of private insurance. But the G.O.P. remains beholden to its richest, most conservative donors, many of whom espouse a doctrine of rolling back the government and cutting taxes, especially taxes applicable to themselves and other very rich people. It was the donors and ideologues, with Ryan as their front man, who led the assault on the Affordable Care Act.
These efforts had put several senators in a difficult place. Moran, who was first elected in 2010 and has a solidly conservative voting record, found himself being forced to defend a set of reforms to Medicaid that meant potentially closing many rural hospitals and taking health-care coverage away from more than a hundred thousand of his fellow-Kansans, according to the Urban Institute. Although Moran cast his decision not to support the revised bill in terms of needing more time for consultations and legislative deliberations, it was clear that he was feeling the political pressure.
In their statements on Monday night, both Moran and Lee said that the revised bill didn’t go far enough in repealing the Affordable Care Act and reducing premiums. This, despite the fact that the measure contained an amendment—modelled on a proposal by Lee—that would have allowed insurers to offer cheap, catastrophic care policies outside the Obamacare insurance exchanges, so long as they also offered a comprehensive option through the exchanges. In recent days, insurers warned that the amendment was completely unworkable and could lead to the collapse of the exchanges. How much further does Lee want to go? In his statement, he also referred to the bill’s failure to abolish all the taxes that the A.C.A. introduced—taxes that only hit the donor class. In other words, the bill didn’t do enough for the wealthy.
Moran, for his part, said, “We must now start fresh with an open legislative process to develop innovative solutions that provide greater personal choice, protections for pre-existing conditions, increased access and lower overall costs for Kansans.” But in order to enable people with preëxisting conditions or modest incomes to obtain health coverage at a reasonable cost, you have to restrict the choices of others. The young and the healthy have to be persuaded, or forced, to join the same risk pools as older and sicker people. Insurers have to be prevented from creaming off low-risk customers into separate markets. Rich people have to be taxed to pay for Medicaid, or for the subsidies that enable working families on modest incomes to buy private insurance. As Milton Friedman noted long ago, there is no free lunch.
Obamacare, for all its complexity and teething problems, was, and is, a serious and comprehensive effort to face up to these difficulties and trade-offs. The Republicans never got serious about how to replace it. They are now paying the price."
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