Monday Morning Thoughts: What We Learned from the Failure of the Health Care Repeal

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When Donald Trump promised that repealing the Affordable Care Act (ACA) would be a top priority, I always believed it would prove to be much more difficult than he thought at the time.  Sure – he could just repeal it, de-fund it, gut it, etc.  But that would have consequences – millions of them.

So the Republicans, wisely, decided to try to piece together a bill that would basically recast the ACA rather than really repeal it.  There were problems with the bill – as we noted, some groups of people would lose their coverage while others would pay more and get less.

Eventually though, it was the Republicans who ended up killing it.

One thought is that the result is precisely what they wanted.  They could claim they tried.  They could pass off the failure onto the Democrats (since the Democrats opposed it), they could continue to blame Obama and the Democrats if the ACA had problems, but they didn’t have to face the serious repercussions of repeal.

On the other hand, maybe the left should not rejoice on this quite so much.  After all, what the failure might point to is the fact that the system is simply ungovernable.  Oh sure, President Trump, like President Obama, has made ample use of the executive order, but governing requires more finesse.  It requires compromise and sacrifice – and President Trump couldn’t even get his own party to buy into that, let alone reaching across the aisle.

For better or worse, President Trump came to Washington promising to “drain the swamp,” to reform the system.

As Harry Enten at FiveThirtyEight.com writes, “But the stunning failure of President Trump and Paul Ryan’s first legislative priority, the American Health Care Act, reveals that he underestimated a unique fracture of the modern Republican Party. Yes, moderate and very conservative Republicans were against the AHCA for very different reasons, making it difficult to find common ground.”

He adds that “there was also a second fissure that helped to take down the American Health Care Act. It was the same one that took down Eric Cantor and John Boehner and that has bedeviled government for years. Call it establishment versus anti-establishment, or belief in governance versus political purity, or fidelity to ideology over party, or more simply: the beliefs of the Freedom Caucus.”

The left has a similar split.  You have what I will call the liberals versus the progressives.  Yes, there are a few more moderate Democrats than there are moderate Republicans, but for the most part the split on the one hand has liberals who are basically establishment types – they supported Hillary Clinton in the primaries, they represent the establishment wing of the Democratic Party that backed Obama, they kept the establishment in charge of the DNC, etc.

Then you have the resurgent progressive wing of the party – the hard core Bernie Sanders supporters that have surged into prominence, in particular after the demise of Hillary Clinton on November 8.  These people want to drain the swamp too – but in their own way.

The year 2018 will be very interesting, as these groups get organized and mobilized.  We saw, locally, huge numbers of people showing up at events that in the past were largely ignored, and we saw a surge sweep in progressive delegates to the state convention – which has a chance to turn the establishment on its head.

A battle to watch will be Kimberly Ellis, who spoke last week at a local event and talked about the need to reform the Democratic Party.  She is running for state party chair against establishment liberal Eric Bauman.  The establishment was strong enough to prevail at the national level, but will they in California?

The bigger issue, however, is my chief concern – whether this country is still governable.  More and more this nation looks like two nations – the people get their news from different sources, they have different world views, and neither side is willing to compromise in order to govern.

The great irony is that the health care bill should have been a perfect place for compromise to occur.  At this point, we were not deciding whether to have a national health care system, but rather the form.

Republicans trying to get a compromise enacted couldn’t have reached across the aisle to see if there was some support for a modified version?  Democrats couldn’t have tried to work to fix some of the problems of the ACA?

At the end of the day, both parties are fractured and neither side is willing to work with the other – or so it appears.

If that is the case, Trump is probably going to find anything that requires congressional approval to be nearly impossible to achieve.  While that may serve the short-term interests of the left and the progressives, I worry about what it means in the long term.

—David M. Greenwald reporting

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About The Author

David Greenwald is the founder, editor, and executive director of the Davis Vanguard. He founded the Vanguard in 2006. David Greenwald moved to Davis in 1996 to attend Graduate School at UC Davis in Political Science. He lives in South Davis with his wife Cecilia Escamilla Greenwald and three children.

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23 thoughts on “Monday Morning Thoughts: What We Learned from the Failure of the Health Care Repeal”

  1. John Hobbs

    “my biggest concern is that the US is now ungovernable”

    No, just ungoverned. Trump is exactly what you see on TV, a pompous ignoramus. Paul Ryan and the rest of the GOP would do well to shun him and forge a coalition with the opposition and some are already moving in that direction.

    The question in my mind is how long Trump will remain in office. I believe he may resign before the Russian chickens come home to roost.

    1. David Greenwald

      I don’t agree just ungoverned, over the last twenty five years it has become increasingly difficult to do the basic things in governance.

      1. John Hobbs

        “Difficult” is not ungovernable. The current GOP leadership has spent most of the last quarter century being obstructionist. Devoid of any original thought or ideas, their mentality precludes cooperation. Do not blame all politicians for failure to do their jobs.

        1. John Hobbs

          Greenwalde-Better get to a doctor, your memory is failing. In 2015 a $305 billion highway bill, a $210 billion medicare “fix,” and the “Every Student Succeeds Act,” which had almost unanimous support, passed and were signed.

    2. Keith O

       Trump is exactly what you see on TV, a pompous ignoramus.

      Ha, just as that deer in the headlight ditz Nancy Pelosi is as she was a huge part of passing Obamacare without any GOP input.

      Remember her infamous quote, “we have to pass the bill so that you can find out what is in it”.

  2. John Hobbs

    “Your comment is awaiting moderation.”

    Of course it is.

    [moderator] Your comment was awaiting moderation because it was reported by multiple people, which makes it go automatically into the moderation queue. Which is usually the cause of moderation actions in your case. I have restored it this time.

  3. Eric Gelber

    Republicans trying to get a compromise enacted couldn’t have reached across the aisle to see if there was some support for a modified version?  Democrats couldn’t have tried to work to fix some of the problems of the ACA?

    Republicans were not interested in working with Democrats and made no effort to do so. They counted on their “majority.” Democrats were not willing to work with “repeal and replace” but may have been open to working on improvements. Thus there was no common ground and no competent leadership in the White House capable of finding any.

  4. Richard C

    For better or worse, President Trump came to Washington promising to “drain the swamp,” to reform the system.

     

    The problem with simplistic slogans like “drain the swamp” is that they are completely meaningless. People can read whatever they want into these phrases so that the polarization we are seeing continues.

  5. Tia Will

    The great irony is that the health care bill should have been a perfect place for compromise to occur.”

    This is true. First, many of the ideas that formed the basis for the ACA were from the Republicans before they decided that they had to oppose it since all things “Obama” had to be opposed. Many different stakeholders were at the table in the shaping of the ACA including mainstream and more innovative health care providers/insurers. For example, when the ACA was being shaped, Kaiser Permanente had a voice in the deliberations. Not so with the GOP plan which basically was done behind closed doors with a very narrow range of input. The only voices that were completely shut out were those calling for single party payer.

    It is certainly true that there is partisan polarization, but it is also true that the current administration and majority party in Congress is not open to hearing ideas that do not conform to their own. This was not true of the Obama administration which was willing to hear many voices regarding health care even if they ultimately had to go it alone.

    1. Keith O

      This was not true of the Obama administration which was willing to hear many voices regarding health care even if they ultimately had to go it alone.

      My memory of this is quite different. The process wasn’t open at all and this article backs me up :

      “The House and Senate plan to put together the final health care reform bill behind closed doors according to an agreement by top Democrats,” House Speaker Nanci Pelosi said today at the White House.

      http://www.cbsnews.com/news/obama-reneges-on-health-care-transparency/

      1. Eric Gelber

        Keith –

        As the article describes, these were final steps to reconcile differences between the Senate and House versions of the bill. Here, on the other hand, Republicans in Congress and the White House showed no interest in working with Democrats from the outset.

        1. Keith O

          As the article describes, these were final steps to reconcile differences between the Senate and House versions of the bill.

          And who came up with the Senate and House versions of the bill?  They had a big majority at that time in order to push their agenda. 

          So please, the Democrats didn’t work with the GOP one iota when it came to enacting Obamacare.  I remember the pictures on the news of the closed doors with only Democrats inside plotting Obamacare.

          1. Don Shor

            That isn’t really true. A good overview here.
            https://www.theatlantic.com/politics/archive/2015/07/the-real-story-of-obamacares-birth/397742/

            Did Obama Jam Through the Affordable Care Act Without Consulting Republicans or Working With Them to Find Bipartisan Cooperation?

            The Obama White House took a number of lessons from the Clinton experience with healthcare policy. First, do not rely on your own, detailed White House plan as the starting point for negotiations in Congress; let Congress work out the structure and details from your  goals. Second, try from an early point to get buy-in from the major actors in the health world, including insurers, physicians, pharmaceutical companies, hospitals and other providers, to at least defuse or minimize their opposition. Third, recognize that the House and Senate are very different institutions, and let each work through its own ideas and plan before finding ways to merge the two into a single bill. Obama and his White House executed those lessons brilliantly.

            There was a fourth lesson: Try in the Senate to find Republican support at an early stage, instead of waiting until the political dynamic shifts toward implacable opposition. The failure to engage John Chafee, Chuck Grassley, Orrin Hatch, and their colleagues at an early point in 1993, when they crafted their own plan and were willing to negotiate and cut a deal, proved deeply damaging, if not deadly in 1994. As the midterms loomed and Democrats were on the defensive, Chafee and his colleagues were told by then-Republican Leader Bob Dole that there would be no deal, period.

            In the House, that lesson was not applicable this time; Eric Cantor and House Republicans had already made it crystal clear that they were not cooperating under any circumstances. There, Democrats debated the issue for several months, but mostly amongst themselves, before introducing a detailed bill that emerged from committees in July 2009 and passing it through the House later in the year with just one Republican vote.
            But with Obama’s blessing, the Senate, through its Finance Committee, took a different tack, and became the fulcrum for a potential grand bargain on health reform. Chairman Max Baucus, in the spring of 2009, signaled his desire to find a bipartisan compromise, working especially closely with Grassley, his dear friend and Republican counterpart, who had been deeply involved in crafting the Republican alternative to Clintoncare. Baucus and Grassley convened an informal group of three Democrats and three Republicans on the committee, which became known as the “Gang of Six.” They covered the parties’ ideological bases; the other GOPers were conservative Mike Enzi of Wyoming and moderate Olympia Snowe of Maine, and the Democrats were liberal Jeff Bingaman of New Mexico and moderate Kent Conrad of North Dakota.

            Baucus very deliberately started the talks with a template that was the core of the 1993-4 Republican plan, built around an individual mandate and exchanges with private insurers—much to the chagrin of many Democrats and liberals who wanted, if not a single-payer system, at least one with a public insurance option. Through the summer, the Gang of Six engaged in detailed discussions and negotiations to turn a template into a plan. But as the summer wore along, it became clear that something had changed; both Grassley and Enzi began to signal that participation in the talks—and their demands for changes in the evolving plan—would not translate into a bipartisan agreement.

            What became clear before September, when the talks fell apart, is that Senate Republican Leader Mitch McConnell had warned both Grassley and Enzi that their futures in the Senate would be much dimmer if they moved toward a deal with the Democrats that would produce legislation to be signed by Barack Obama. They both listened to their leader. An early embrace by both of the framework turned to shrill anti-reform rhetoric by Grassley—talking, for example, about death panels that would kill grandma—and statements by Enzi that he was not going to sign on to a deal. The talks, nonetheless, continued into September, and the emerging plan was at least accepted in its first major test by the third Republican Gang member, Olympia Snowe (even if she later joined every one of her colleagues to vote against the plan on the floor of the Senate.)

            Obama could have moved earlier to blow the whistle on the faux negotiations; he did not, as he held out hope that a plan that was fundamentally built on Republican ideas would still, in the end, garner at least some Republican support. He and Senate Democratic leaders held their fire even as Grassley and Enzi, in the negotiations, fought for some serious changes in a plan that neither would ever consider supporting in the end. If Obama had, as conventional wisdom holds, jammed health reform through at the earliest opportunity, there would have been votes in the Senate Finance Committee in June or July of 2009, as there were in the House. Instead, the votes came significantly later.

            To be sure, the extended negotiations via the Gang of Six made a big difference in the ultimate success of the reform, but for other reasons. When Republicans like Hatch and Grassley began to write op-eds and trash the individual mandate, which they had earlier championed, as unconstitutional and abominable, it convinced conservative Democrats in the Senate that every honest effort to engage Republicans in the reform effort had been tried and cynically rebuffed. So when the crucial votes came in the Senate, in late December 2009, Harry Reid succeeded in the near-impossible feat of getting all 60 Democrats, from Socialist Bernie Sanders and liberal Barbara Boxer to conservatives Joe Lieberman, Ben Nelson, Mark Pryor, and Blanche Lincoln, to vote for cloture, to end the Republican filibuster, and to pass their version of the bill. All sixty were needed because every single Republican in the Senate voted against cloture and against the bill. Was this simply a matter of principle? The answer to that question was provided at a later point by Mitch McConnell, who made clear that the unified opposition was a ruthlessly pragmatic political tactic. He said, “It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out.”

            McConnell’s hardball strategy certainly worked as a political weapon.

            The delays engendered in large part by the extended negotiations with Republicans in the Gang of Six, meant in the end that the normal legislative process—in which separate bills passed by House and Senate would be reconciled in a conference committee—was not going to work in this case. When the vacancy caused by the death of Senator Edward M. Kennedy was filled via a January 2010 special election by Republican Scott Brown, Democrats lost their 60th vote—and the McConnell strategy meant that there was no way, no matter what changes Democrats were willing to make in the final package, that there would be a single Republican vote to get them past the filibuster hurdle. Hence, the fallback to using reconciliation to bypass the filibuster in the Senate, and the inability to smooth out the rough edges and awkward language in the final bill that was enacted.

            McConnell’s hardball strategy certainly worked as a political weapon. The narrative of Obama steamrollering over Republicans and enacting an unconstitutional bill that brought America much closer to socialism worked like a charm to stimulate conservative and Republican anger. The 2010 midterm elections resulted in huge Republican gains across the country, a Republican majority in the House, and a much narrower Democratic majority in the Senate. But the strategy also prevented Republicans from having a much bigger impact on the healthcare reform bill—some level of cooperation would have meant more sweeping malpractice reform and reductions in defensive medicine, and more market-oriented approaches to many areas of health delivery. It also meant that the standard technical corrections bill that every major policy change requires was unavailable in this case, creating its own challenges for implementation of the Affordable Care Act.

        2. Howard P

          So please, the Democrats didn’t work with the GOP one iota when it came to enacting Obamacare.

          So, the mature, effective governance approach now is for “payback”?  Just like holding up a presidential nominee for the SC?  For 9 -10 months?  Without one hearing?

          At least the prez’s nominee is having hearings…

        3. Jim Frame

          Umm, how many Democrats voted for AHCA?

          Exactly as many as the number of Republicans that voted for it.  Hint, it rhymes with “won.”

           

           

        4. Keith O

          Thanks, you proved my point.  Both sides practiced partisanship when it came to healthcare.  So for those just pointing a finger Republicans need to look at their own party too.

        5. Howard P

          Keith (your 4:37 post)…

          You “prove” one of my beliefs… that the two party system is on the brink of failure… they’d rather piss @/on one another (and on the people) than fish, cut bait and/or actually govern…

          I fully expect nothing ‘real’ to happen for at least 2 years, on anything important or mission critical.   “The swamp” grows… some of the fauna have re-aligned…

      2. Tia Will

        Keith

        As pointed out in a limited way by Eric, this as only after many  months of meetings with multiple stakeholders, of which I am aware indirectly from following it on the news, but more directly from updates on Kaiser involvement from our physician in chief over the year in which the plan was being drafted.

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