Exorcise the repeal and replace demon

Now What? 

Well that didn’t take long. After seven years of promises that Republicans had a better plan to cover more people at lower cost than ObamaCare, and after dozens of votes to repeal the Affordable Care Act, it took less than three weeks for it all to collapse in fiasco and finger pointing.

{mosads}Now what?

One thing seems certain:  there is no more appetite among the bulk of the Republican caucus to revisit repealing and replacing the ACA.   The lone exceptions seem to be the House Freedom Caucus and Speaker Paul Ryan (R-Wis.), both of whom continue to seek to breathe life into repeal and replace.  

As long as the budget reconciliation instructions remain in effect for healthcare, revival is a possibility – and if there’s one lesson to be learned from the ACA, it’s that there’s a big difference between mostly dead and all dead, to borrow from the Princess Bride.  Most Republicans, however, are now desperately trying to figure out what to tell their constituents, with those Members who were brave or foolhardy enough to stick their necks out to endorse Trumpcare having the added burden of trying to explain their support for a bill that was roundly loathed.

The consensus Republican view on messaging seems to be, “Move along, folks. Nothing to see.  Hey, look over there…it’s tax reform.” Whether major tax legislation remains possible in a context of bitter infighting and some daunting budget math remains to be seen, but it’s clear that none of the committee chairs want to spend another nanosecond talking about repeal and replace.

Nor is there impetus from the Senate, where Senate Majority Leader Mitch McConnell (R-Ky.), ever the master tactician, adopted a strategy of waiting for the House to move first, which ensured his caucus a remarkable win-win:  not only did they avoid touching the steaming mess of Trumpcare, but they also escaped blame for its demise.  McConnell will be the last to disturb that happy state of affairs.

Does that mean nothing happens on healthcare for the rest of the Congress?

If President Trump has his way, the answer would be yes.  His preferred solution is to do nothing and hope the ACA “explodes”.  If he gets his wish (and there is abundant evidence that he won’t), it will be his own strongest supporters who feel the pain.  Insurer participation in ACA markets is robust in urban areas that vote heavily Democratic.  The counties that have only a single insurer in the exchanges are almost all solidly Republican rural areas in the South and West.  

Even if the president is willing to let local insurance markets crash, it seems unlikely that members of Congress, who are on the ballot in just over 19 months, would be willing to go along just to support the president’s vindictiveness.  Having walked the plank once already on healthcare, House Republicans are unlikely to do so again.

In predicting the future, the lessons of past major health reforms may now apply.  In the 1960’s, after a bitter partisan fight, Republicans recognized that Medicare was, in Ryan’s words about the ACA, “the law of the land.”  Rather than fighting to repeal Medicare, Republicans have largely worked with Democrats to make incremental changes to the program, with only occasional (and unsuccessful) attempts to curtail the scope of implemented benefits.  I suspect even Ryan has now given up on turning Medicare into an insurance coupon plan.  In the 1990s, after tempers had cooled following the defeat of the Clinton health plan, Republicans and Democrats got together on health insurance portability in 1996 and children’s health in 1997. 

Something similar may now happen with the ACA, which may, at long last, become a more normal piece of law that is subject to revision and adjustment but not threatened with extirpation.  There are initial signs that this may already be happening.  Energy & Commerce committee chair Greg Walden (R-Ore.) has announced that his committee will consider policies on exchanges, CHIP, and health centers – policy areas that are remarkable for their unremarkableness.  They are the normal workaday bills on health policy in Washington that usually pass by voice votes on slow afternoons. And amen for that.

The reverberations of the TrumpCare fiasco will not stop at the Beltway.  Governors and state legislatures who have as yet declined to expand Medicaid so as not to appear to be giving aid and comfort to ObamaCare may now cast envious glances across their borders to states that have brought in millions of extra Federal dollars through expansion.  With the repeal and replace effort having collapsed so spectacularly, they may well conclude that the time has come to swallow ideology and just go for the cash.  Whatever the motivation, low-income Americans will be the beneficiaries.

If the country is lucky, this week’s debacle will have exorcised the repeal and replace demon once and for all, so Congress can get down to the solid, often arcane, but vitally important business of enacting policies to improve health.  Standing in the way is a President whose idea of a bipartisan approach to healthcare is to taunt Democrats that they will crawl through the wreckage of Obamacare to beg for his help.  The choice will lie with Congressional Republicans – do they bind themselves to the vindictive wish for destruction expressed by President Trump, or do they ignore eruptions from the White House and get on with the unspectacular business of governing?

David Bowen, PhD, is Executive Vice President and Global Practice Director for Healthcare at Hill+Knowlton Strategies

The views expressed by this author are their own and are not the views of The Hill.