Why Repeal and Replace Is Going So Badly

UNITED STATES - SEPTEMBER 27: Speaker of the House Paul Ryan, R-Wisc., holds up his "A Better Way" Pamphlet" as he speaks to the press following the House Republican Conference meeting in the Capitol on Tuesday, Sept... UNITED STATES - SEPTEMBER 27: Speaker of the House Paul Ryan, R-Wisc., holds up his "A Better Way" Pamphlet" as he speaks to the press following the House Republican Conference meeting in the Capitol on Tuesday, Sept. 27, 2016. (Photo By Bill Clark/CQ Roll Call) (CQ Roll Call via AP Images) MORE LESS
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The outlook for the GOP leaderships’ ‘repeal and replace’ bill looks bleak. That said, I would not underestimate the ability of GOP leaders to get their members to vote for basically anything in the crunch. Also remember that House Republicans have a 20+ vote cushion. But it’s worth reviewing what I believe are three key reasons why the current legislation looks to be on life support just a day after it was released.

1: Reality. Going back seven years the Republican party has not only been committed to opposing and repealing Obamacare. It has grown to the level of almost being a core element of party ideology – not any policy on health care but opposing “Obamacare”. It was the core of the 2014 election, the core of the 2012 election and a major point in the 2016 election. But while this was happening, there was a less visible but equally consequential development. The GOP largely accepted the premise of Obamacare. And by premise here I mean the premise that the people who received coverage under the Affordable Care Act should have gotten coverage and should be able to keep their coverage. This was the basis of the evolution from “repeal” to “repeal and replace” to “repeal and replace … it with something even better.”

The fact that Republican elected officials may not have really gotten religion on near-universal coverage isn’t the point. They accepted the premise in their public messaging. This is why we have gone years with the GOP not being able to come up with a plan. It’s not hard to find a plan. There are a million potential plans, the most simple of which is simply to repeal the ACA altogether. It’s not that Republicans have been lazy or haven’t focused. Coming up with a plan means squaring an impossible circle to bring together those who want a more palatable/’market based’ approach to ensure coverage for roughly the same amount of people and those who want to cut the taxes Obamacare was based on and let everyone fend for themselves. In a sense it’s a battle within the minds of people who pushed a strong political argument with no ability to follow through if they regained power. To the extent it is a factional contest, there are varying differences of principle, different kinds of districts and states where elected officials can or cannot give free reign to their ideology purity. But that’s the gist of the problem.

There are numerous complexities to health care provision. You can save money by creating efficiencies, functioning markets, compelling everyone into the risk pools, etc. But at the end of the day, covering people, making quality health care available to millions more people costs money. It also involves regulation to avoid various sorts of adverse selection. There is no way to evade this iron law. More money means more coverage and more care. And vice versa. They haven’t squared this circle because it is unsquarable. This first attempt gives everyone something to dislike. That is exacerbated by the fact that the bill is devised to serve a political goal – getting past the GOP’s ‘repeal and replace’ crisis – rather than a policy goal – insuring people. Because of that the details don’t really add up. Not only is it skimpy in what it provides, while maintaining the ‘entitlement’ elements which piss off the far-right, it is such a hodgepodge that it probably won’t work in structural terms. You can say you’ll continue the ban denial of coverage for pre-existing conditions. But you need to have enough money in the system to make that viable for for-profit insurance providers.

2. Nonsense Debt. A year ago I discussed the concept of “nonsense debt” as a key element in Donald Trump’s rise to power. You can read my full argument in the linked article. But the gist is that Republicans spent years since 2008 (actually before but especially since 2008) stoking their base with increasingly fantastical and ridiculous claims. Obamacare has death panels. Christians are a persecuted minority majority in the United States. We’ll build a fifty foot wall and make Mexico pay for it. This hokum drove huge levels of party enthusiasm and outrage which paid massive electoral dividends. But it also made the GOP ripe for takeover by an antic huckster like Donald Trump. To take just one small but illustrative example, back in February 2016 when Trump told Chris Cuomo that he probably gets audited so much because he’s a “strong Christian”, Republicans weren’t in much position to take him to task for this ridiculous answer since they’d spent years preaching to their base that just that kind of thing happens all the time.

This nonsense debt also altered the composition of Congress and especially the House Republican caucus. In each successive election of the Obama era, Republicans have bred for more and more extreme Representatives, more and more fed on nonsense debt. To put it more concretely, they have been reared not only on nonsense debt but never exposed to the realities of governing. As one of my colleagues put it, “if you think of it in evolutionary terms, the GOP has self-selected for hair on fire, apocalyptic conservatives for the last 10 years (maybe longer) — actual policy knowledge is not a priority. Nor is legislative acumen.” That reality is now colliding head on with the need to fulfill a campaign promise in a way that doesn’t upend tens of millions of people’s lives or lose Republicans their majority in 2018.

3: Presidents Matter. It is in the nature of our system that presidents gather around themselves some element of a personality cult. What is the work of hundreds or even thousands of people who make up a presidential administration gets wrapped into the person of the President, if only as a shorthand. And yet, in our constitutional system, the President is actually a critical driver of legislation – whether that is “the President” or the actual person holding the office. Our constitutional system has numerous stakeholders and power centers, both formal and informal. Things are easier to stop than propel forward. The only power center with sufficient gravitational force to have much hope of organizing the others together is the President – especially in his first weeks and months in office. Of course legislation can and does arise on Capitol Hill. Perhaps it should happen that way more often. But when it’s difficult lawmaking with major hurdles and stakeholders standing in the way, the mix of formal and informal powers, favors and threats, public presence, the ability to protect or punish – these are all critical to galvanizing the different structures of government to move in one direction.

This is something President Trump has shown virtually no interest in doing. We’re at roughly a month and a half into the administration. The GOP has unified control of the government and yet no significant legislation has moved at all. That is a stunning reality which the storm and chaos of Trump’s short presidency has largely obscured. But it is an almost unprecedented development. Some of this may be an inherent limitation because the President came into office as a minority President. But as I argued a month ago, the President simply has no appetite for the hard work of passing laws. He has defaulted to rolling out executive order after executive order, in most cases Potemkin decrees with vaguely legalistic language and limited actual impact. Like so much with Trump, it’s a mix of authoritarianism on the one hand and impatience and flimflam on the other. The upshot isn’t so much a poor man’s as a lazy man’s authoritarianism.

But there are no laws. And big change in the American system requires laws. Whether it’s on Obamacare or tax reform or anything else. It’s hard. President Trump doesn’t want to do it.

Now, President Obama also came to rely on executive orders in the latter part of his presidency. But remember, he faced an implacable Republican Congress. Trump faces a pliant one. Even with total control of the government, executive orders are all he has energy to focus on. When it’s not executive orders, President Trump is off on rage tangents yelling at the air over fantasies about his predecessor, well out of office, plotting against him. I talk DC lobbyists now and then, ones in Trump’s crosshairs and those he supposedly favors and none of them have any idea what he’s going to do from one day to the next. That’s not strategic ambiguity. It just keeps anyone from doing anything. Could Trump put more time into this if he weren’t in the midst of a mini-constitutional crisis over accusing his predecessor of illegally wire-tapping him? Probably so …

As I noted in Point #1, Republicans gained electoral advantage by setting a trap they really had no way to solve. But presidential engagement and focus would have made a great deal of difference. It’s not there.

At the end of the day, the consequences for Republicans if they can’t do anything are astonishingly large. I would not count them out. But it’s a tall order. And it’s not just passage. It’s surviving the consequences next year.

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