There are already reams of postmortems about last week’s collapse of the drive to repeal the Affordable Care Act. It will probably become a case study for students of policy and politics (file under “what not to do”). Nevertheless, with the benefit of a few days of reflection, we can reach some good conclusions about what went down and draw some lessons for the future.
Why Did the AHCA Fail?
There is no shortage of figures to credit (or blame, depending on your point of view) for the demise of the American Health Care Act (AHCA): Democrats (in general and former Obama officials, in particular); the Freedom Caucus in the House; House Speaker Paul Ryan; the organizers at MoveOn and Indivisible; the Trump administration’s own incompetence; and even the GEICO lizard. So, what really killed the AHCA?
There is some truth in the answer “all of the above” (well, maybe not the lizard). Part of the reason is indeed the division within the Republican Party and the extremism and intransigence of many of its members. The reason GOP party leaders did not have a workable replacement plan ready to go by now should be obvious, and it is not solely because there was no point in doing the heavy policy and political lifting while Obama was president. Republican political leaders didn’t have a replacement plan ready because a large segment of the party is unwilling to confront the fact that the pillars of the ACA – competitive private insurance markets, tax credits for affordability and some kind of hedge against free-riding/ adverse selection–are essentially Republican health policy.
Even the minimal inclusion of these elements in AHCA, sweetened with big tax cuts for the rich and a big Medicaid cut, were too much for the Freedom Caucus. This is the same group of extremists that shut down the government back in 2013 and drove John Boehner (who must be laughing his head off) from the speakership.
In an effort to appease this faction, the “finished product” that almost reached the House floor didn’t stop with cutting the tax credits and Medicaid coverage the ACA provided. It undermined care for millions of children, seniors and people with disabilities, included a whopping premium increase for older adults and created a new opportunity for insurers to deny coverage to people with many serious and chronic conditions. “Trumpcare” (or “Ryancare,” if you prefer) was also a major economic blow to providers of care and state budgets. In short, it was not just an attack on the health and economic security of millions of people, it was a full-frontal assault on an economic sector that accounts for millions of jobs and about one-sixth of all the economic activity in the country.
But blaming the Freedom Caucus lets too many others off the hook. Let’s not forget that Speaker Ryan was actually the chief architect of the bill, which the Trump administration enthusiastically embraced.
This Is What Democracy Looks Like
Intra-party infighting has gotten a lot of press coverage, but it is only part of the story, and not the most important part. The rapid mobilization of opposition was critical. It forced Republican leaders to abandon their “repeal and delay” strategy and put an alternative to the ACA on the table. Once people got a good look at “replace” – 24 million losing coverage, $880 billion in reduced federal support to states, job losses, higher out-of-pocket costs – and heard the compelling stories of people whose health and lives would be in jeopardy, thousands took to the streets and flooded the Congressional switchboard in protest.
Nor was this just a victory of the “left” or a small set of organizations or individuals. It was a victory for an ideologically heterogeneous public engaging in civic action to stop a narrow faction of extremists bent on undermining their health care. You cannot mobilize people around something about which they do not care. Fortunately, people care about health care. Above all, as David Brooks succinctly summed up, “The Republican Health Care bill failed because it was a bad bill that had almost no authentic public support. It took benefits away from tens of millions of vulnerable people in order to give tax breaks to the rich few.” It turns out that health care is too important and too personal to be used as a stalking horse for a big tax cut for the rich.
What Were They Thinking?
In hindsight, it is less remarkable that the American people soundly rejected this atrocious legislation and more surprising that its backers had the gall to bring it forward in the first place. However, despite this ignominious defeat, there is no indication that Trump or the Congressional Republicans have shifted into genuine problem-solving mode. They are still wedded to their narrative about how terrible the ACA is and unwilling to make peace with the idea that everyone should have access to affordable, meaningful coverage. Moreover, they are still scheming to bring another terrible repeal bill back to the floor or to undermine the ACA via administrative means.
No Time for a Victory Lap
In recent days, Speaker Ryan has indicated that he is not giving up his dream of cutting people off health care, which he has nursed since his frat-party days. And HHS Secretary Price has refused to commit to effective implementation of the law. Faced with all of these threats, there is a real risk that insurers will either pull out of the program or demand another big premium increase as a hedge against the uncertainty. Activists must be prepared to expose and push back against the next wave of attacks. But we must also do more.
Despite the gains made by the ACA, there are real problems in our health care system. These problems demand real fixes, not a toxic stew of tax cuts and ideologically driven nostrums that will make things worse, not better.
That means we need to advance policies to ensure adequate choice of plans, help the people who still cannot afford their premiums and reduce high cost sharing especially for people with chronic conditions that will cause them to hit their out-of-pocket maximum year after year. We need to confront the persistent racial disparities in health coverage and outcomes. We also need to address issues the ACA left unaddressed, such as high drug prices and inadequate coverage for services that allow older adults to stay in their homes.
Making progress on these fronts will require us to internalize two important lessons from recent events.
First, be prepared. While prospects for progressive action in Washington, DC and in many states may look dim right now, articulating a vision of what we are for and doing the policy work to back it up will help us make the most of opportunity when it arrives. Being prepared also means talking to the public to ensure that the proposals we advance have popular support.
Second, build unity. Democrats were greatly aided by their unity in opposition to AHCA, as were Republicans when they were in the opposition. However, building unity around what you are for is much harder than building it around what you are against, as we just saw. A lot of work went into building not just the policy but the political consensus that resulted in passage of the ACA and it extended far beyond elected officials. That consensus, which also led to the defeat of AHCA, included a broad swath of consumer, civic, faith and patient advocacy organizations, as well as most other health care stakeholders. We need similar unity now to advance solutions that address the real pressing problems we still confront.
The recent debate has shown that people are hungry for real solutions to their health care problems, not snake oil falsely marketed as “patient-centered” care. Our task in the weeks and months ahead is to build momentum for the former while continuing to defend against the latter.