Pinkerton: The Way Forward on Repealing and Replacing Obamacare

I. The End of the Beginning of Repeal and Replace 

It’s sort of poetic, in a sad way, that the resignation of Health and Human Services Secretary Tom Price on September 29 coincided so closely with the expiration of the 2017 budget resolution on September 30.  Those two events signaled the end, at least for now, of Congressional Republicans’ efforts to repeal and replace Obamacare through reconciliation–that being the arcane process by which the GOP could have avoided a crippling Democratic filibuster in the Senate.

So yes, those two events—Price’s resignation and the budget’s expiration—close the 2017 chapter of the ongoing healthcare fight.  However, the fight will likely continue next year.  And so with that in mind, we might consider ways to shift an approach that failed in 2017 to a strategy that could win in 2018.

We’ll focus on that new strategy in Part 2; for now, let’s look at what didn’t work this year, and why.

II. The Roll Call of Disappointment 

For those who might be gluttons for detail, the brawl over repealing and (sort of) replacing Obamacare fell into four main phases:

First, there was the fight over the first version of the American Health Care Act, which died in the House in March, only to reborn in May, thanks to the MacArthur amendment, whereupon it passed the House by a slim four-vote margin.

Second, the Senate then took up the House bill, re-dubbing it the Better Care Reconciliation Act (BCRA); that bill sank in late June.

Third, the Senate’s BCRA was then reworked and revived; it was now officially the Health Care Freedom Act, although it was more often called “skinny repeal.”  That bill was defeated by Sen. John McCain’s dramatic “thumbs down” vote in the wee hours of July 27.  (We can note that these three bills all had one thing in common: They were insufficiently thought through, and were too obviously budget cuts, as opposed to true healthcare replacements—that’s why they failed.)

Fourth, on September 13, Republican Sens. Lindsey Graham and Bill Cassidy introduced a fourth repeal and replace bill; they were soon joined by GOP Sens. Dean Heller and Ron Johnson, and so the legislation came to be known as Graham-Cassidy-Heller-Johnson (GCHJ).  This bill was different from the first three, because it was based on a genuinely new idea, which we will get to in the next installment.  Yet unfortunately, GCHJ was sprung too late in the political season to be adequately vetted and analyzed—so it never got a fair and careful hearing that might have improved it enough to secure actual passage.  It was this GCHJ bill that burned hot for a week or so, and then guttered out in the days before that September 30 deadline.

So now, in October, having seen what has happened, we can ask: What could happen?  What will come next?  What will be the fate of GOP health efforts in the 2018 fiscal year?  This much we know: Most Republicans in Congress, in the White House, and at the grassroots level—and especially among the donor class—want to see the anti-Obamacare effort continue.

Most likely, future GOP efforts will focus on the last of the repeal bills, GCHJ, because that was the most plausible of them, and, frankly, the most innovative and clever, because it promised the most in the way of actually replacing Obamacare with a better idea, as opposed to just repealing it and leaving people hanging.  In other words, GCHJ had, and still has, the potential truly to transform American healthcare.

Yet at the same time, we must be mindful that even GCHJ didn’t get through a Republican Congress this year.  So it, too, will need some tweaking—perhaps even significant tweaking—if it ever is to become law.  Why?  Because while the American people have hardly been following the ins and outs of all this legislative horse-trading over the past nine months, they nevertheless have developed strong feelings about their own healthcare.

III. A Timeout to Hear From the American People

In 2017, Congressional Republicans took the view that action on Obamacare was the paramount objective.  And in the most literal sense, that was the case: The anti-Obamacare push came ahead of legislative action on immigration, trade, tax reform, missile defense, you name it.  Hill GOP thinking could be summed up this way: We promised we would repeal and replace Obamacare, and so now we must do it. 

It’s always laudable, of course, to seek to keep one’s promises, and, in general, it’s smart politics, too.

However, sometimes the political landscape changes, and in such an circumstance, it’s wise at least to consider what those changes might mean for practical politicos seeking to pass a bill—and, of course, to win re-election.

That is, in times of flux, what was smart yesterday might no longer be smart today. And so what should politicians do when the political situation changes?  To be sure, steadfastness is a virtue, but are stubbornness and refusal to adapt in the face of failure also virtues?

It would seem that at a minimum, input from the voters—it’s their country, after all—needs to be considered with an eye toward making necessary     course-corrections.

So let’s start with the basic question: What do the American people think of Obamacare?  As we shall see, that’s been changing.

Back in March 23, 2010, when President Obama signed the Patient Protection and Affordable Care Act into law, “Obamacare” was slightly more popular than not.  According to a tracking poll from the Kaiser Family Foundation, 46 percent of Americans supported the law back then, while 40 percent were opposed.

Yet unfortunately for the Democrats, the Republican Tea Party immediately rose up, rhetorical guns blazing, and so the popularity of Obamacare started to slip.

Indeed, if we examine the same Kaiser poll, which has been following public opinion on Obamacare steadily for the past seven years, we can see that the law’s unpopularity spiked in both 2010 and 2014.  And that was painfully bad timing, of course, for Democratic candidates in the midterm Congressional elections in those years.  Indeed, at its lowest ebb, in July 2014, Obamacare was 16 points “under water”; that is, 37 percent of Americans supported it, while 53 percent were opposed.  Given those numbers, at that time, it’s easy to see how opposition to Obamacare became orthodoxy for the GOP.

But then, in 2015 and 2016, Obamacare’s popularity started to tick back up again, even if it was still below the water’s surface: In November 2016, 43 percent supported it, while 45 percent were against it.  Still, even with those narrowing numbers, it’s easy to see why Republicans stayed emboldened and on the offensive.

Yet after the 2016 election, even as the Democrats were laid low at the ballot box, the idea of Obamacare continued its climb: Through almost all of 2017, the health law has been more popular than unpopular, albeit by slim margins.  In September, for example, it was two points up.  (Other multi-year polling series, such as those from Gallup and Pew, tell the same overall story as Kaiser.)

So what happened?  Why did the American people—the swing vote, at least—  change sides on Obamacare?

We might speculate that in people’s minds, it was one thing to be against “Obamacare” in the abstract—that is, when Obama’s presence in the White House, veto pen in hand, meant that the law wasn’t going anywhere, no matter what Republicans did.

And yet the issue looked a lot different when Donald Trump was in the White House, ready to sign any repeal bill.  That is, when the prospect of repeal became tangible, more Americans started to get cold feet.  (And of course, blind hatred of anything Trump might touch could be another factor in the opinion-shift.)

In the meantime, something else was happening, at an even deeper psychological level: The American people were starting to change their mind on the gut issue of healthcare entitlement—that is, whether or not every citizen has the “right” to healthcare.  Such a pro-statist shift in thinking might be horrifying to libertarians and other purists, but the data are clear enough.

In the last half-decade, we have seen a increase in support for the basic idea that the government ought to guarantee people’s health coverage.  Indeed, an AP-NORC poll from July found that 62 percent of Americans agree with the statement, “It’s the federal government’s responsibility to make sure that all Americans have healthcare coverage.”

Yet if we think about it, these changes shouldn’t be too much of a shock: The country has changed.  For many years now, much of the middle class has seen its wages eroding, and as a result, many folks are less interested in the ideology of health “freedom” and more interested in the affordability of being healthy.  To put it another way, an affluent middle class might be inclined to see healthcare through a Republican lens, but the former middle class—having been busted back down into the working class—seems more inclined to see healthcare through a Democratic lens.

Most dramatically, in the past few years, a harrowing new concern, the opioid crisis—which killed almost 53,000 Americans in 2015 and more than 64,000 in 2016—has scrambled people’s thinking about healthcare.   That is, when one’s neighbors are dying from a sudden epidemic, perhaps it’s time to think about getting help from Uncle Sam, not spurning it.

Meanwhile, in 2016, along came Donald Trump, speaking a very different language about healthcare than most Republicans before him.  To hear Trump talk, the key issue in healthcare wasn’t the abstraction of “liberty”—as in, liberty from Obamacare bureaucrats— but rather, the practical issue of better healthcare, even if it came from the government.

Specifically, Trump pledged that he would make no cuts in such key government  health programs as Medicare and Medicaid and, at the same time, he pledged to vastly improve care at the Veterans Administration.

Indeed, Trump made his maverick stance into a selling point; as he tweeted, “The Republicans who want to cut SS & Medicaid are wrong. A robust economy will Make America Great Again!”  (To be sure, Trump also talked about repealing and replacing Obamacare, but never with any specificity; that is, he never sought a mandate for any particular approach—and so he never got one.)

The 2016 election results clinched the change—the Republican Party was now, presumably, the Trump Party.  And with that change came a change in the intra-party dynamic of the GOP; as we all know, Candidate Trump became President-elect Trump because he carried a slew of states that Republicans hadn’t won in decades.  And yet those new GOP voters helped shift the center of gravity with the GOP in a new and less libertarian direction.

So the lesson was clear, or at least it should have been: Trump won those crucial additional electoral votes because he was a different kind of Republican, with a less ideological, more practical message—including on healthcare.  If the old GOP message was, “You’ll be free,” the new Trump message was, “I will help you.”

Okay, so we can sum up: First, there’s been a significant increase in support for guaranteed government health insurance in the past few years, and second, Trump’s victory occurred in part because he sidestepped the old ideological fight over healthcare, replacing it with a newer, less hard-edged approach.

Yet as we all know, during his 2016-17 transition to power, Trump came to agree, at least most of the time—that is, when he wasn’t labelling it as “mean”—with the more orthodox Republican approach to repeal and replace.

In other words, perhaps strangely, Trump joined with Congressional Republicans to grasp a shrinking straw.  That is, in 2017, Republicans moved ahead with their favored vision of repealing and replacing Obamacare even as the tide of public opinion was drifting the other way.

Indeed, it was this popular tide that kept pushing back the GOP armada.  In March, a Quinnipiac poll found that just 17 percent of Americans supported the then-GOP healthcare bill, while 56 percent opposed it.  By May, asked about a slightly different version, that number had bumped up a bit, to 21 percent in favor, and yet with the same 56 percent against.  In July, another poll, on another iteration of the GOP plan, found just 12 percent in support and 53 percent against.  And just last month, when asked about the newest GCHJ health bill, 20 percent supported it, and yet 52 percent remained opposed.

To put it mildly, these are daunting numbers for anyone in GOP politics.  And yet most Republicans, true to their word, hung in there, even as it became more and more clear that nothing was going to pass—at least not in this fiscal year.

We can step back and see: The ultimate problem was that when Republicans promised to “repeal and replace,” people could believe that the “repeal” part was real, but they were skeptical that “replace” was genuine.  Or, to put that another way, the GOP was obviously eager to get rid of Obamacare, but it didn’t to appear to be nearly as committed actually to delivering healthcare to ordinary people.

We can conclude that that Republicans have been so intent on getting something done, as soon as possible, that they neglected the hard work of actually persuading voters that they had the better health plan.  As has been said, politics is the slow boring of hard boards, and so there can never be a respite from the patient work of political persuasion.  It’s simple: In a democracy, you have to have the people with you. 

In the meantime, the Democrats, having created their own antimatter Tea Parties, were now the energized opposition; it was liberals and leftists, not Tea Partiers, who were flooding town halls and filling up social media with Obamacare activism—pro-O, of course.

The result of all this ferment has been a continuing shift in public opinion.  Today, according to Kaiser, a full 78 percent of Americans think the Trump administration should be working to make Obamacare succeed, while just 17 percent want to see the law fail.

As an aside, we can observe that with lopsided numbers such as these, the Senate confirmation hearings for Tom Price’s replacement at HHS will likely be stormy, as   Democrats—perhaps joined by some Republicans—insist that the new HHS wannabe commits to making Obamacare succeed.

IV. No More Trench Warfare: The Need for a Different Strategy 

In a three–part series for Breitbart News in July and August, this author outlined his assessment of the then-ongoing struggle to repeal and replace.  Identifying a particularly glum centennial comparison, he compared the GOP slog on healthcare to World War One trench warfare—specifically, the British attack on the German fortifications at Passchendaele, Belgium.  The result, over four months in late 1917, was nearly half-a-million British casualties for the gain of a mile or two of mud.

The problem for the British was that they were simply doing the same thing, the same way, over and again—and getting, of course, the same bad result.  That is, it was the same daylight infantry charge across “no-man’s land” in the face of German barbed wire, as well as machine-gun blasts and artillery barrages.  Back then, the British generals simply couldn’t think of another way to fight.  Sad!

Only late in the war did the British, now joined by the Americans, figure out how to use new ideas—namely, the effective coordination of the tank and the airplane—to break the stalemate of trench warfare.  So finally, after many false starts, the new year, 1918, brought victory to the Allies.

So we can see: Even the toughest problems can be solved with new thinking.  And  today, too, there’s hope, for the Republicans’ repeal-and-replace effort.  As smart strategists say, Any situation can be improved.  And yet at the same time, it’s just as axiomatic that doing the same thing, one more time, won’t work out any better for the GOP in 2018 than it did for them in 2017—or for the British in 1917.  Ardent enthusiasm is no substitute for sober strategy.

Happily, the most recent upgrade in the GOP health bill, the new GCHJ version, is a bona fide new idea.  And as such, it offers considerable hope for Republicans in the future—and hope, too, for the country.

In the next installment, we will see how the basic idea of GCHJ, tweaked a little—or maybe a lot—might yet yield a breakthrough.

Next: Building a better healthcare mousetrap.