The American Health Care Act is dead… at least for now. Next week House conservatives may wake up to the fact that they sided with Democrats to kill a bill that repealed a large part of the Affordable Care Act and defunded Planned Parenthood. Perhaps the most disturbing thing about the failure of the AHCA is that no better or more realistic alternative for repealing and replacing Obamacare has been offered by the party’s dissidents.
The fundamental problem faced by the GOP is a mathematical one. The Affordable Care Act was passed with 60 Democrat votes in the Senate to overcome a Republican filibuster. It was then amended by a reconciliation bill that only required a simple majority. In 2010, Democrats had 60 seats in the Senate. Today, the Republicans have 52 and five of those are not reliable for a clean repeal. The numbers are just not there for a clean repeal so where does the Republican repeal and replace effort go from here?
Perhaps nowhere. If President Trump stands by his ultimatum that if the AHCA failed that he would bypass Obamacare and move on to other issues, the repeal effort may be dead in the water for the foreseeable future.
On the other hand, while President Trump may not be committed to a repeal of Obamacare, many other Republicans are. However, without the bully pulpit of the presidency backing them, repeal is even more difficult than before.
Republicans face two giant hurdles in their quest to repeal and replace Obamacare. The first is finding a consensus between moderate and conservative Republicans on health policy. The differences range from what to do about the Medicaid expansion to how to treat tax credits for health insurance premiums to defunding Planned Parenthood (Susan Collins, I’m glaring in your direction.) The second problem is finding 60 votes to defeat the Democrat filibuster that is certain to come with any repeal or reform legislation other than a budget reconciliation.
The death of the AHCA does nothing to bridge the gap between the Freedom Caucus and Republican moderates. Like the AHCA, any future bill will have to try to appeal to both wings of the party and, as a result, will probably be reviled by both sides.
Given that the Republicans have only 52 votes available, there are only three viable strategies for repealing the Affordable Care Act.
1. The Nuclear Option. Republicans can change Senate rules to eliminate the filibuster. The problem is that they still fall short of 51 votes due to probable defections by Susan Collins and the Medicaid Four. Without 51 votes, eliminating the filibuster is pointless and counterproductive. There is a good chance that Republicans will decide to eliminate the filibuster to ram other bills through, but this strategy seems unlikely to help them on Obamacare.
2. Stall and wait for 60 Senate votes. The Democrats forced the ACA through with a supermajority of 60 votes. Likewise, the GOP could force a repeal if they had 60 votes. The last time that Republicans held a 60-seat majority was the 61st Congress from 1909 through 1911.
Nevertheless, this is not as unlikely as it sounds. There is a chance for a big GOP win in the Senate in 2018 because 10 Democrat seats in red states are vulnerable to Republican challengers.
The downside is that the 2018 elections are almost two years away and a lot can happen. President Trump is not popular and Republican voters are seething at the way the health care bill was handled. Republicans have blown easy Senate races many times before. A big Republican win in 2018 is probably made less likely if the health insurance system implodes on President Trump’s watch.
3. Compromise. In today’s political environment, compromise is often seen as a dirty word. Nevertheless, it will be necessary to pass repeal and replace legislation any time soon. Not only will Republicans have to compromise among themselves, something the Freedom Caucus has been largely unwilling to do thus far, they will also have to compromise with Democrats. This is likely to be as unappealing as it sounds.
Democrats hold the key to reforming the health care system. Even if large parts of Obamacare can be repealed through reconciliation, much of the health care reform on the Republican agenda will have to pass a Democrat filibuster. With a minimum of eight Democrat votes needed, Republicans will have to learn give-and-take or resign themselves to at least two years of gridlock.
The failure to repeal Obamacare is not about a lack of will among most Republicans. It is about a lack of Republican votes in Congress, even though they hold a slim majority. If Republicans really want to rid the country of Obamacare, they must go beyond “just say ‘no’” to find a realistic legislative pathway to repeal. This will most likely involve compromising on an imperfect bill that can garner a majority.