President Donald Trump had an epiphany this week about the seven-year-old Republican crusade to “repeal and replace” Obamacare. After his past promises of “insurance for everybody” and “I am going to take care of everybody,” Trump had an admission to make to the nation’s governors on Monday:
“I have to tell you, it’s an incredibly complex subject. Nobody knew that health care could be so complicated.”
Of course, almost everyone knew that. After all, U.S. health care spending has reached $3.2 trillion per year. That figure doesn’t just represent almost 18 percent of the nation’s gross domestic product: it’s nearly double the investment that America’s economic competitors make for health care systems generally rated better than our own. Complicating matters further, the United States has not one but four health care systems: private insurance for individuals and families provided by employers or purchased in the market, Medicaid for low-income Americans and elderly nursing care, Medicare for senior citizens and the disabled, and the VA system for military veterans.
But the evident frustration of the Trump administration and GOP leaders in Congress in fulfilling their pledge to replace the 2010 Patient Protection and Affordable Care Act has two causes of the Republicans’ own making.
First, “replacing Obamacare” has a very specific meaning. For starters, any GOP alternative must not only enable insurance for over 20 million Americans as the ACA does, but must also prevent millions more from losing coverage during any transition period. Crucially, a true replacement for Obamacare must likewise require coverage for mammograms, colonoscopies, annual check-ups and prenatal care. Just as important, no plan touted as an alternative can roll back the ACA’s extensive protections against the worst practices of the insurance industry, including refusing to insure those with pre-existing conditions, using “rescission” to drop coverage for the newly sick, imposing annual and lifetime benefits caps and barring coverage for adult children under age 26 on parents’ policies. And no Republican plan is a “better way” if it increases the national debt, something the nonpartisan Congressional Budget Office (CBO) has always concluded Obamacare does not.
That brings us to the Republicans’ second self-inflicted wound.
President Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell have set very high expectations for their Obamacare replacement proposal. Yet almost seven years after McConnell declared his party’s slogan for the 2010 midterm would be “repeal and replace, repeal and replace, repeal and replace,” the GOP hasn’t come close to a blueprint that can check off all the boxes described above. There’s no mystery as to why.
For a generation, the GOP has never offered a serious plan to provide universal health care coverage for the American people. Instead, Republicans have only put up straw men as part of their scorched-earth campaign to prevent Democrats from succeeding in doing so.
That’s also why the buzzwords Ryan, Trump, and his Health and Human Services Secretary Tom Price are kicking around—providing too-small tax credits, letting insurers sell across state lines, setting up high-risk pools, block granting Medicaid, encouraging health savings accounts (HSAs), capping malpractice awards, and so on—sound so sickeningly familiar. After all, that’s pretty much the same straw man Bill Kristol erected almost 25 years ago to stop HillaryCare. In one form or another, Republicans have been recycling it ever since.
A little history is in order to help tell the tale of the GOP’s “grass is always greener” health care reform scam. In November 1991, Democrat Harris Wofford stunned Republican Dick Thornburgh in a special election for the Pennsylvania Senate seat held by the late John Heinz. As the New York Times reported at the time, Wofford’s surprise win by an even more surprising margin was seen as a cautionary tale for President George H.W. Bush’s upcoming reelection campaign. “In a trial run for themes that are certain to be important next year,” the Times said of Wofford, “he concentrated on the need for national health insurance and the problems with the economy and offered general pledges to help the middle class.”
That message wasn’t lost on Vice President Dan Quayle’s chief of staff, William Kristol, especially after the Clinton-Gore ticket sent his boss packing in November 1992. With the newly inaugurated President Bill Clinton and his wife Hillary determined to make health care reform a centerpiece of their first term, the new chairman of the Project for the Republican Future went to work.
In his infamous Dec. 3, 1993 memo titled "Defeating President Clinton's Health Care Proposal," Kristol warned Republicans that in their path back to power "the first step in that process must be the unqualified political defeat of the Clinton health care proposal":
Its rejection by Congress and the public would be a monumental setback for the president; and an incontestable piece of evidence that Democratic welfare-state liberalism remains firmly in retreat…
Its passage in the short run will do nothing to hurt (and everything to help) Democratic electoral prospects in 1996. But the long-term political effects of a successful Clinton health care bill will be even worse--much worse. It will relegitimize middle-class dependence for 'security' on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government.
A month later, Kristol detailed "How to Oppose the Health Plan—and Why" with a set of bullet points that by now should look very familiar:
- Reform insurance markets to make health insurance stable and portable
- Limit pre-existing-condition restrictions under employer health plans
- Eliminate barriers to small business insurance pools
- Lower insurance premiums by making them tax-deductible
- Permit the establishment of medical savings accounts
- Reduce costs through malpractice reform
- Simplify health care paperwork through administrative reforms
- Reduce Medicaid and Medicare expenses by lifting the regulatory burden on states
- Provide health insurance tax credits or vouchers to low-income families
As the American Prospect recalled, Kristol's war plan:
Darkly warned that a Democratic victory would save Clinton's political career, revive the politics of the welfare state, and ensure Democratic majorities far into the future. "Any Republican urge to negotiate a 'least bad' compromise with the Democrats, and thereby gain momentary public credit for helping the president 'do something' about health care, should be resisted," wrote Kristol. Republican pollster Bill McInturff advised Congressional Republicans that success in the 1994 midterm elections required "not having health care pass."
So, Republicans and their media water carriers followed Kristol's advice to the letter. In the Senate, longtime health care reform supporter Bob Dole adopted Kristol's mantra, declaring "Our country has health care problems, but no health care crisis." Long before she introduced the easily debunked Obamacare "death panels" fraud, Betsy McCaughey almost singlehandedly undid the Clinton health care reform effort with the false claim that "the law will prevent you from going outside the system to buy basic health coverage you think is better."
By the 1994 midterm elections, HillaryCare was dead and with it the Democratic majority in the House of Representatives. For Republicans, among the lessons of ’94 was this iron rule. GOP opposition to Democratic health care reform must be total. And key to successful Republican non-cooperation was a permanent placeholder designed not to enable “insurance for everybody” but to stop Democrats from doing so.
And so it’s been for more than 20 years. In 1996, Republican presidential nominee Bob Dole mocked “Clinton’s insistence that turning the American health care system over to the Federal Government is the only solution.” Instead, Dole offered warmed-over proposals like tax deductions for purchasing health insurance and tax incentives for medical savings accounts. In 2006, President Bush used his State of the Union address to put health savings accounts at the center of his reform “agenda.” As the Los Angeles Times explained at the time:
The idea is that by coupling a bare-bones, high-deductible insurance policy with an account into which people can deposit money tax-free and withdraw it for medical expenses, individuals will have a greater financial stake in getting reasonably priced care.
But as the Times also explained, “Most elements of the administration's latest package are not new.” As a look back at the Bush White House health care fact sheet reveals, many of the bullet points can trace their paternity back to Bill Kristol:
George W. Bush’s health care reform plan exhumed the rotting corpse of the Kristol memo.
During the 2008 election, the crisis of American health care worsened with the recession which began the previous December. With 47 million uninsured, another 25 million underinsured, and 30 percent of Americans struggling to pay medical bills, Republican nominee John McCain largely regurgitated the Bush plan. Whereas Bush’s scheme “would have replaced employer tax breaks for health insurance with a $15,000 tax deduction for married couples,” the Washington Post explained that “McCain's prescription would seek to lure workers away from their company health plans with a $5,000 family tax credit and a promise that, left to their own devices, they would be able to find cheaper insurance that is more tailored to their health-care needs and not tied to a particular job.” While the question of tax credits (which benefit lower-income taxpayers) versus tax deductions (which generally benefit wealthier Americans who itemize their tax returns) still plagues Republicans, the other GOP pablum about high-risk pools, “association” health plans, tort reform and interstate insurance sales was all in there. It’s no wonder Ed Kilgore concluded that “McCainCare Equals BushCare.”
Ditto for the 2012 version of RomneyCare. To court hardline conservative primary voters, Mitt Romney had to abandon his innovative 2006 Massachusetts health care reform on which Obamacare was largely based. Like McCain, Romney, too, offered an unfunded $1 trillion program of giving Americans a tax break to buy their own health plans. But while Bush’s program was estimated to cover 9 million more Americans, the Los Angeles Times warned:
Critics and independent analysts say the impact would probably leave a larger number of Americans without insurance...While offering consumers more choices, Romney's plan would give companies strong incentives to stop providing insurance to workers. It also would overhaul the 46-year-old Medicare and Medicaid programs for the elderly, poor and disabled.
It's no wonder Ezra Klein asked during the Romney-Obama contest, "Do Republicans Really Want Universal Health Care?" His answer came as no surprise:
Voters this year will choose between one party that supports universal health care and one that doesn’t, with health insurance for as many as 50 million voters hanging in the balance.
But a lot has changed since Barack Obama’s re-election triumph over Gov. Romney. Within days of Obama’s election in November 2008, conservatives like Michael Cannon of the Cato Institute and founder of the “Anti-Universal Coverage Club,” warned, “Blocking Obama's health plan is key to GOP's survival.” He wasn’t alone in fretting that “if Democrats take the White House and pass a big-government healthcare plan, that's it.” But by 2014, the Affordable Care Act, despite its own hiccups and unprecedented GOP sabotage, had now been fully implemented. And as I noted back in January, the American people are getting a much clearer picture of what will ensue if Republicans repeal Obamacare with nothing to replace it:
For starters, a complete repeal of Obamacare now would leave an estimated 23 million more Americans without health insurance. Delaying it by up to four years past the 2020 election—as some Republicans are now contemplating—would be even worse, with a staggering 30 million people losing coverage as the individual market would enter a real "death spiral." With the repeal of the ACA's consumer protections like the ban on insurers' refusing to issue policies to those with pre-existing conditions, roughly 52 million Americans (27 percent of those under age 65) could find themselves at risk.
As a result, millions currently insured under Obamacare would face the prospect of postponed care and possible financial ruin. The GOP's body count would be a gruesome one, too: thousands of those left uninsured would needlessly die each year. It should come as no surprise that Donald Trump's own supporters, a group that will be disproportionately hit by the Obamacare repeal, are increasingly worried that the 45th president will effectively become a one-man death panel. And it's no wonder that organizations of doctors, hospitals and insurers have issued warnings about euthanizing the ACA without a replacement plan in place.
Repealing Obamacare using the budget reconciliation process would leave 30 million more uninsured.
It's no wonder Republicans are panicked and divided about what to do now. The politics of Obamacare have flipped, with the ACA now enjoying a surge in polling while Republican Congress members are under siege from their constituents. In the states, GOP governors who elected to expand Medicaid coverage such as John Kasich of Ohio and Rick Snyder of Michigan are warning their colleagues that thanks to that Obamacare provision, “Literally we’ve saved lives.” Congressional hardliners, including North Carolina Rep. Mark Meadows and Sens. Ted Cruz, Mike Lee and Rand Paul want to move full steam ahead on repeal. While they oppose the House GOP’s leaked proposal to offer age-based, refundable tax credits for the purchase of health insurance as a “a new entitlement program and a new tax increase,” Democrats are pounding Speaker Ryan over the dramatic increase in health care costs his plan would entail, especially for older Americans.
The House GOP “plan” means higher costs for the older and poorer, and savings for the wealthy.
It’s no wonder, as Vox reported, that Thursday’s “unveiling” of the current draft legislation is being treated like “an intelligence intercept” for Republican eyes only. And given the dire assessment the Congressional Budget Office has always forecast for their Obamacare repeal schemes, it’s no surprise House Republicans may vote on their legislation before the CBO even has a chance to score it.
CBO: GOP Obamacare repeal increases the national debt, raises premiums and cost millions coverage.
Despite the inescapable conclusions that any GOP “replacement” plan for Obamacare will cause millions of Americans to lose health insurance, produce financial hardship for millions more and lead to thousands of needless deaths annually, all while increasing the national debt, House Speaker Paul Ryan is happy. That’s because in his address to Congress last week, President Trump was speaking his language. Trump didn’t call for banning insurers from discriminating against those with pre-existing conditions or enable Americans to keep their current insurance, only promising to “ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.” The ACA’s consumer protections, monthly subsidies and medical cost-sharing for lower income Americans will be gone, replaced with “tax credits and expanded health savings accounts—but it must be the plan they want, not the plan forced on them by the government.” Ryan’s goal of reversing Obamacare’s Medicaid expansion and converting the shriveled program into block grants under President Trump becomes giving “our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.” Trump reliably reproduced the Republican malpractice myth by proclaiming “we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance.” Last, but not least:
Finally, the time has come to give Americans the freedom to purchase health insurance across state lines — creating a truly competitive national marketplace that will bring cost way down and provide far better care.
Trump didn’t mention some of the GOP’s old standards, like high-risk pools (which “were not successful overall at providing broad access to high-quality, affordable coverage”). Small business pools or “association health plans” (AHP’s) were left unmentioned Tuesday night as well. “Continuous coverage protection” safeguards only those who don’t let their insurance coverage lapse. These and other staples have been in every “plan” Paul Ryan has championed, including his 2016 “Better Way.”
Nevertheless, Speaker Ryan was thrilled after Trump’s speech before the joint session of Congress. “We’re all working on the same page,” Ryan said, adding:
"I think he did a fantastic job on health care. He articulated exactly the response that we’re working on, that we all believe is necessary to repeal and replace Obamacare with a much better system."
But the emerging Republican alternative to the Affordable Care Act isn’t—and can’t be—“a much better system” than Obamacare. If passed, its failure is certain precisely because it was never meant to be passed. For 25 years, Republicans repeatedly resurrected their straw man not so they could provide universal health coverage for the American people, but to ensure that Democrats didn’t.
Note: Back in 1993, Utah Sen. Orrin Hatch and 20 Republican co-sponsors introduced legislation very similar to what President Obama signed into law as the Affordable Care Act. Asked in 2009 by Andrea Mitchell why “you and other Republicans came up with counteroffers to the Clinton White House and the individual mandate was perfectly acceptable to Republicans back then,” Senator Hatch gave the game away. “Well, it really wasn't. We were fighting Hillarycare at that time.” As for why he was waging a “holy war” to stop Obamacare, Hatch told CBN:
“If they get there, of course, you're going to have a very rough time having a two-party system in this country, because almost everybody's going to say, ‘All we ever were, all we ever are, all we ever hope to be depends on the Democratic Party.’"
