The meticulously plotted Republican plan to repeal the Affordable Care Act and have that repeal vetoed by President Obama culminates this week. The House of Representatives has voted to eliminate the law dozens of times over the last few Congresses, but either Democratic control of the Senate or Democrats’ use of the filibuster has kept the repeal from going any further. So after last year’s midterm elections, in which the GOP gained control of the Senate, Majority Leader Mitch McConnell agreed to use the reconciliation process to get the repeal over the finish line. (Reconciliation is the one-off parliamentary maneuver that only requires a 51-vote majority.) After an expected marathon of votes on dumb amendments heading into Thursday, the bill should pass, paving the way for Obama to veto the dickens out of it.
Republicans are going through the Kabuki of passing a doomed bill for a number of reasons. Once it became clear that this Congress wasn’t going to use reconciliation to pass anything that could make its way into law, the GOP decided that it might as well burn the reconciliation tool on a messaging bill. The message here is to clarify to Republican voters, ahead of the presidential election, that all they need to eliminate the ghastly scourge of expanded access to medical care is a new, conservative butt in the Oval Office swivel chair. As useless messaging bills go, you could do worse. (Though, it’s worth pointing out that this bill should also send a message to the Democratic base to show up and vote if they want to save the Affordable Care Act.)
This reconciliation process has been carried out as the trial run for an actual ACA repeal after the 2016 elections, as Republican legislators have done reconnaissance on all the procedural traps that might occur for the real deal. By those standards it’s been largely successful. Though the bill will not be a total repeal, it does eliminate much of the law’s core infrastructure, its revenues and its outlays, even if it can’t weed out every last regulation under reconciliation, because some don’t directly pertain to the budget.
The question this process hasn’t resolved, though, is this: How comfortable will Republicans be passing such legislation when it actually has the potential to become law? While the trial run has clarified how to surpass the various procedural hurdles toward repeal, it’s also exposed the difficult political considerations Republicans will have to take into account if and when they get their chance to do it for real.
Two political considerations that will give some Republicans the most pause in a hypothetical joint effort with a Republican president are the central pillars to the law: the Medicaid expansion and subsidies for purchasing insurance plans on government-established private insurance exchanges. A reconciliation repeal bill that the House passed in October eliminated the most unpopular parts of the bill, like the individual and employer mandates, but it did not touch either the Medicaid expansion or the subsidies. The political problem here was fairly straightforward: Voters (“people”) don’t like having their health insurance taken away.
Conservative Sens. Marco Rubio, Mike Lee, and Ted Cruz, along with pressure groups like Heritage Action, rejected the House-passed bill as a cowardly dodge that broke a promise to voters who demanded full repeal. After some hesitation, McConnell decided to include repeal of the Medicaid expansion (over the course of a two-year phaseout period) and the subsidies into the package. Heritage and the hold-out senators appeared to be satisfied.
But now Republicans at the other end of the spectrum aren’t, according to Politico: “[A] number of Republican senators from states that have expanded Medicaid voiced concerns about the message the party would be sending to the thousands of constituents that would lose their health care under the GOP’s bill.” Indeed: Repealing Obamacare would involve repealing Obamacare. But McConnell and his team were able to soothe these fears with a comical reply: Don’t worry, it’s not like this repeal that we so desperately claim to want will become law. “[S]enators were reminded,” Politico reported, “that the president would veto the repeal bill anyway, meaning Republicans could vote on the measure without having to deal with the political risks of actually making major changes to existing law.” And Sen. John McCain, speaking at an event Wednesday morning, said that he “would probably vote for” the package, even though “it does provide me with discomfort.” Not quite the discomfort that poor people would feel once their newly received access to medical care is snatched away, but discomfort, sure.
The theory of the dry run that probably couldn’t pass as a real run is that by 2017, Republicans won’t have to worry as much about the consequences of revoking peoples’ bennies because, by then, they’ll have an adequate replacement plan ready to go. Will they, though? It’s been nearly six years since the ACA passed, and Republicans have been promising for all that time that they’ll have an Obamacare replacement plan ready ... soon. They’ve had trouble agreeing on a comprehensive alternative around which all factions of the party can rally, though. It’s not because they lack the proper imagination. It’s because covering the same number of people that the ACA covers without spending much money is an extremely difficult task.
Republicans are on the cusp of showing that they’re procedurally capable of repealing most of the ACA should they unify control of the federal government in next year’s election, but they’ve also revealed that they’re far from politically committed. We’re already witnessing on the state level what happens when Republicans who campaign on undoing the Medicaid expansion arrive in a position to do so: They get cold feet. If Republicans in 2017 are finally able to gut the law, they’ll have to make a choice: Suffer the political consequences of taking away health coverage from millions, or suffer the political consequences of breaking a central promise to the Republican base. Neither sounds particularly fun.