This is it. This week House Republicans will unveil their plan to replace Obamacare.
Except by “plan” they mean be a “broad outline,” and by “replace” they mean without giving any specific dollar amounts that would show how far they’d go to guarantee that Americans don’t lose coverage, according to a report last week in The Hill.
House Speaker Paul Ryan (R-WI) will roll out the policy paper at a Wednesday event at the American Enterprise Institute, the conservative think tank in Washington. It comes as a part of series of general initiatives — “A Better Way,” as Ryan is calling it — which the speaker has described as showing voters what Republicans are for, not just what they’re against.
Ryan promised such an agenda declaration before Donald Trump emerged as the party’s nominee, but the proposals now serve the additional purpose of counter-messaging against a presumptive nominee who has shown little interest in health care policy — or in conservative approaches to many other policy areas.
This week’s outline also comes after years of promises that Republicans will craft legislation that serves as an alternative to the Affordable Care Act, promises that came as they voted to repeal it dozens of times. Their struggle to settle on a replacement plan has been evident in both the absence of consensus legislation over the last half decade or so — during which Republicans reclaimed the House and then the Senate — as well as in the public intra-party squabbling that emerged any time it looked like the ACA was being threatened.
The impasse has revealed the policy complications facing Republicans — not the least of which is that conservatives are in deep disagreement over the basic question of whether the government should try to make coverage more accessible. It also serves as a reminder of the political costs that come with any effort that would take away the Obamacare benefits their constituents are already counting on.
The GOP’s replacement promises began almost immediately after Obamacare was signed in March 2010. Republicans included a “plan to repeal and replace the government takeover of health care” in their September 2010 Pledge to America, and after the Tea Party wave gave them the House by historical margins, GOP leadership continued to say lawmakers were working on an alternative.
Another national election came and went without any major legislation, but by 2013 conservative health policy experts began ringing the alarms bells that the longer lawmakers waited to outline their alternative, the harder it would be to implement.
“What Republicans can and should do is offer the public something better,” conservative health wonks Ramesh Ponnuru and Yuval Levin wrote in a 2013 Wall Street Journal op-ed. “Some Republicans think that political success requires nothing more than watching ObamaCare fail. But if the new system quickly implodes, that would be all the more reason to have an alternative on hand — other than another leftward move toward single payer. And it might not implode so quickly.”
Obamacare celebrated it fourth, fifth and sixth birthdays, without any major alternative legislation being proposed, even though in January 2014, then-House Majority Leader Eric Cantor promised a vote on an alternative that year.
To be fair, there were some small-scale replacement bills introduced, usually with just a handful of co-sponsors, but none were taken up by the broader caucus for serious consideration.
More revealing still was that any time Republicans were called upon to pass anything that headed in the direction of replacement, the party would crumble over the political trade-offs that would have come with doing anything proactive on health care policy.
In 2013, a GOP House bill that would have cut billions of dollars from one Obamacare program in order to boost funding for its temporary high-risk pool plan was abruptly withdrawn because some Republicans objected to government spending on an idea that even many conservative health wonks approve.
“Subsidizing health care is not what Republicans should be about,” Rep. Raul Labrador (R-ID), a member of the hard right House Freedom Caucus, said at the time.
A 2015 Supreme Court case that threatened to dismantle a key part of the law made the stakes for Republicans much higher. The lawsuit challenged the legality of subsidies available on some of the exchanges, and, had it been successful, would have destabilized the individual exchanges to the point of chaos.
Again still, there was no clear decision among Republicans on how far to go to blunt the damage a ruling against the ACA would have inflicted, a rift that reflected the meta-debate over government involvement in the health insurance industry.
Now this reality is running into a presidential election cycle in which the candidate topping the GOP ticket has shown no interest in leading his party through the quagmire. Donald Trump has paid lip service to the idea of repealing Obamacare, but when asked what he would replaced with it, the real estate mogul bumbled his way through a set of promises that spelled something that sounded — to conservatives’ horror — exactly like Obamacare.
Without specific numbers or the level of detail that comes with actual legislation, it’s hard to imagine the plan Republicans will unveil this week will actually draw much of a contrast.