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Tuesday, March 28, 2017

The Demise of the GOP Health Plan – Why It Happened and Where Do We Go from Here

Ron Pollack

Executive Director

The demise of the GOP’s bill to repeal the Affordable Care Act was truly an extraordinary event! For the first time in many years, Republicans controlled all the decision-making levers of the legislative process: the White House, the Senate, and the House of Representatives. They had crusaded for seven years to repeal and replace the ACA and, for an even longer period, were chomping at the bit to reorganize (aka cut funding from) the safety-net Medicaid program. These were unmistakable top priorities for the Republican leadership. Yet they failed.

So why did this pernicious political crusade fail? And, now that this legislative effort appears to be history, where do we go from here?

What happened to the Republican effort to repeal the Affordable Care Act?

Many commentators ascribe the bill’s demise to splits within the Republican Party. While it was obvious that the right-hand simply couldn’t coordinate with the far-right-hand, there were other very significant dynamics that caused the GOP’s retreat and defeat.

Republican health care bill was terrible policy. First and foremost, the bill was downright lousy and destructive. Here’s a quick recap of the damage it would have caused. The bill would have:

  • Caused 24 million people to lose health coverage. It would have significantly increased out-of-pocket (premium and deductible) costs for others, especially seniors and moderate-income families.
  • Eliminated the essential health benefits – the list of health care services that the ACA requires insurers to cover – thus making coverage largely meaningless.
  • Ended the successful expansion of Medicaid in 31 states and the District of Columbia.
  • Jeopardized Medicaid’s safety-net lifeline for 70 million people who benefit from the program.
  • Cut funding for the most successful reproductive health provider in the nation, Planned Parenthood Federation of America.

It is no surprise, therefore, that the public opposed this legislation by a whopping 56-17 margin.

The Republican bill proposed a massive redistribution of wealth from poorer people to the wealthy and corporations. Second, opinion leaders across the country quickly learned, through analyses issued both by advocacy organizations as well as the non-partisan Congressional Budget Office (CBO), that the GOP bill was a gross example of Robin Hood in reverse.

While $880 billion was intended to be withdrawn from Medicaid for the poor, almost $600 billion in unneeded tax breaks would have been showered on the wealthy and special interest groups. While regressive economics is too often a hallmark of Republican policymaking, this proposal was far too extreme.

On-the-ground activism by people defending the ACA. Third, the mobilization by supporters of the ACA and other progressives was impressive. At town hall meetings across the country, and through ongoing calls to legislators, people across the country expressed their dismay and fears about losing health coverage.

This mobilization was partially prompted by a new national coalition, Protect Our Care, which Families USA helped to form, and was also catalyzed by spontaneously formed and existing grassroots organizations. Together, these efforts encouraged people to share their family stories, thereby humanizing the debate. Thankfully, no false claims about the bill drowned out these voices of desperation.

Health stakeholder groups opposed the Republican bill. Fourth, unlike the lead-up to the ACA, Republicans made no meaningful effort to reach out to and consult with health stakeholder organizations. As a result, hospital organizations expressed dismay that they would become economically vulnerable by being forced to provide uncompensated care to many more people who would no longer have insurance.

Groups representing seniors, such as AARP, condemned the increasing out-of-pocket costs faced by 50-64-year-olds. Physician and nurse organizations lambasted the extensive future loss of health coverage by their patients. Groups representing people with serious health conditions or disabilities expressed their fears that life-saving health care would be withdrawn. Managed care plans criticized the major cutbacks in Medicaid. And consumer organizations, like Families USA, issued repeated warnings about the future deterioration of America’s health care system.

This combination of factors played an integral role in the demise of the GOP’s health bill. By the time President Trump and House Speaker Ryan pulled the bill to avoid an embarrassing vote, virtually no group supported the legislation – and even typically conservative institutions were criticizing it because of the harm it would cause.

This, therefore, was not simply the story of a couple dozen renegade Republican House members who revolted against their party’s leadership. It was much larger than that.

What’s next for health care advocates?

President Trump is not the kind of person who gracefully accepts defeat. Nor is he introspective enough to recognize that his boasts about replacing the ACA with a “great” plan was totally vacuous.

Instead, as the bill was withdrawn and the ACA survived, he blustered that “Obamacare unfortunately will explode. It’s going to have a very bad year.” To those listening carefully, this sounded less like a prediction and more like a threat.

Indeed, if the President violates his oath of office and fails to faithfully execute the law of the land (the ACA), the historic statute can be undermined in numerous ways, including:

  • States might be granted section 1115 and 1332 waivers that run counter to the law’s purposes and proscriptions.
  • The Administration might make it more difficult for consumers to enroll in marketplace coverage by refusing to support navigators and assisters, and, as it did at the end of January, curtail outreach advertising.
  • The Department of Health and Human Services (HHS) might issue regulations designed to thwart effective implementation of the ACA.
  • Insurers might be denied funding the law provides them for enrollees’ cost-sharing reductions as well as reinsurance payments, thereby hastening their exodus from the marketplace.
  • The Administration may refuse to enforce the personal coverage responsibility provision (the individual mandate) by refusing to enforce its penalties, resulting in fewer young, healthy people getting enrolled, with the inevitable result that premiums would escalate.

As a result, job number one for health care advocates is to do whatever is necessary to prevent this sabotaging of the ACA.

This will mean litigating against the Administration when it flouts the law.

It will mean casting a bright public spotlight on the Administration’s harmful actions, demonstrating that ACA-related problems were caused by Trump’s recalcitrance, not inherent flaws in the statute.

And it will mean the ongoing telling of real-life stories of people who are being harmed by the Administration’s sabotaging actions.

Of comparable importance will be for advocates to actively support the funding extension of the Children’s Health Insurance Program (CHIP). Funding for the program expires at the end of this September. As a crucial part of these efforts, advocates will need to thwart possible efforts by the Administration and congressional leadership to hold that program’s extension hostage to legislative riders that undermine the ACA or Medicaid.

If these attacks are successfully avoided, perhaps we will sometime get to the point when bipartisan leaders might come together in good faith to improve, not destroy, America’s health care system. That time is overdue.

Ron Pollack steps down as executive director on March 31. To keep up with Ron's commentaries on important health care justice issues of the day, subscribe to his blog Frontline: Commentaries about Health Policy and Politics.