Now that the clock has run out on the 2017 budget resolution, the Republican drive to repeal the Affordable Care Act and undermine the Medicaid program has hit a pause. However, like a dangerous disease in remission, it would be a huge mistake to conclude that the repeal effort is gone for good.
It is sometimes said the definition of insanity is doing the same thing over and over and expecting a different result, in which case, the most recent iteration of repeal—Graham-Cassidy-Heller-Johnson— was truly insane. The bill had the same basic features as previous failed proposals and in some respects was even worse. Mark Twain said “there is nothing to be learned from the second kick of a mule.” This wisdom was apparently lost on many Senate Republicans who insisted on making another futile effort to rip health insurance away from millions of people and undermine the financial stability of health care providers and state government. However, just because the majority party doesn’t seem to have learned anything from nine months of failure doesn't mean we shouldn’t.
What are ACA repeal proponents’ motivation?
For starters, we need to understand and come to terms with one of the most bizarre features of this whole debate—the absence of any constituency whatsoever within the health care system itself in support of the snake oil that the Trump administration and congressional Republicans were selling. Typically, some segment of the relevant industry would championed this type of rollback of consumer protections—i.e. we would expect big banks and other financial firms to support rolling back consumer protections in Dodd-Frank or energy companies or auto-makers to back weakening environmental protections.
In this case, however, almost every stakeholder group opposed the plan. This included not only the “usual suspects” such as the voluntary health groups, AARP and unions, but also doctors, hospitals, insurers, all 50 state Medicaid Directors and more. The only exception was Big Pharma, but even they stayed silent on sidelines and did not back “repeal and destroy.”
Not only were various stakeholder opposed, but repeal was (and is) deeply unpopular with the American public. While repealing “Obamacare” remains popular with Republican voters in the abstract, the actual repeal bills Congress advanced were far less so. The difference in the level of support between “repeal and replace” as an abstract idea and support for specific repeal bills can be explained at least in part by the deep dishonesty of the repeal enterprise.
Although the critiques of the ACA often had at least a grain of truth (premiums and cost sharing are too high and not enough people get help), the actual repeal proposals only exacerbated things that people don’t like about the current system. At the same time, they reintroduced a basket of deplorable policies no one wants to see come back (e.g. charging people more if they have a health problem and undermining Medicaid coverage for millions of children, seniors and people with disabilities whose coverage had nothing whatsoever to do with the ACA).
The best explanation for the Republican Party’s almost maniacal fixation on such a disastrous agenda in the face of such solid opposition is that the right-wing money-machine associated with the Kochs and Mercers, demands it. And what this means is there is absolutely no reason to believe repeal attempts will abate as long as Congress is dominated by members who are beholden to or afraid of this claque of wealthy extremists who are hostile not only to the ACA but also to the reforms of the Great Society and even the New Deal.
What’s more, although repeal was defeated repeatedly, it was not defeated decisively. Only Senators Collins, McCain and Paul publicly took a hard “no” position prior to the final demise of the latest repeal bill. Although many Senators may have had misgivings, most were afraid to stand up and be counted publicly. Even Senator Murkowski, who was a critical opponent of repeal in August, issued an equivocal statement that can only have been encouraging to those who want to try for repeal yet again.
What all of this means for the resistance
First, there is no final victory until there are different people in charge. Disregard every reporter or pundit who tells you that repeal is dead. It is not. While it may assume different forms (I’m thinking Sauron in Lord of the Rings for you Tolkien geeks, and you know who you are…), it will not go away. Only political defeat will remove the threat. Will ACA repeal reemerge as part of FY 2018 reconciliation bill congressional Republicans are using to advance tax cuts? The ‘smart money’ says no, but the smart money also said there wouldn’t be another repeal push after the defeat in August. The truth is we cannot be sure. Both the House and Senate budget resolutions appear to allow for another push on ACA repeal and Medicaid cuts. We should not trust to either the good intentions or what would appear to be common sense of congressional leaders. Instead, we must keep up the pressure against repeal albeit at a less frenetic pace (for now).
Second, we need to embrace an ‘all in’ strategy. It is impossible to tease out and attribute the defeat of repeal to one aspect of the campaign. Everything was necessary, and no one strategy alone was sufficient. Massive public resistance was critical, so were personal stories, hard-hitting analytic pieces and the mobilization of stakeholders.
Third, we must redouble our efforts at the state level to make the ACA work as well as possible and shine a bright light on the ongoing efforts to sabotage the law.
Finally, as this improbable year—a year that has given us both the election of Donald Trump and the defeat of ACA repeal despite Republican control of the White House and both branches of Congress—enters its final quarter, we should take heart from our success. Although the norms of democratic governance are being challenged, the power of resistance has proven itself stronger than anyone would have believed last November. We have made and can make a difference.
With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.