Republicans had quite the racket going—a very long, nearly successful con. For seven years, they convinced much of the country that every health care–related problem people faced could be directly attributed to Obamacare, a socialist plot enacted by Democratic votes and signed into law by nefarious Barack Obama.
If premiums or medical inflation were increasing at any rate, it was because of Obamacare. If you had to wait 20 minutes in the doctor’s office waiting room, it was because of Obamacare. The opioid crisis? Obamacare. If your child didn’t get a lollipop after her well visit? All Obamacare.
Republicans, in conditioning voters to direct all complaints to the Democratic Party, developed one of the most potent political tools in recent memory. The drawn-out, frequently ugly path of the Affordable Care Act’s passage helped the GOP take the House in 2010. The failure of its rollout helped the party capture the Senate in 2014. A sharp upward correction in premiums helped television’s Donald Trump become president of the United States. Obamacare had, and has, serious problems, though not ones that couldn’t and can’t be mended with the good-faith legislative maintenance it has been denied since enactment. Republicans opted, instead, to keep their fingerprints off the issue to maximize their political gains.
This worked so, so well for them—until they had to do something about it. Once Republicans had the power to erase the law they had spent nearly a decade deriding—with neither a Democratic Senate to block the dozens of single-page full repeal bills the House would pass nor a Democratic White House to veto their “test” bills—they found that repealing Obamacare in a meaningful, structural sense would be both unpopular and something most of them didn’t really want to do.
Did any Republicans in Congress actually want to “repeal Obamacare” on the policy merits? Certainly not the moderates, even though they too had villianized the law. The rank and file are just sheep, willing to vote for whichever bill the leadership tells them to. Obamacare repeal was never an animating spiritual force. It was mostly a bloc of conservatives in both chambers—the Freedom Caucus in the House, and Sens. Mike Lee, Rand Paul, and Ted Cruz in the Senate—who wanted to do away with the policy architecture that Obamacare installed, instead of just reaping the political benefits of opposing it. And that’s just not enough people.
Despite the aura around it, Obamacare, in its individual market reforms, is essentially just the idea that sick people should be able to purchase quality insurance at roughly the same price as healthy people. All of the law’s regulations, carrots, and sticks—guaranteed issue, community rating, essential health benefits, the individual mandate, subsidies, single risk pools, etc.—were put in place to make such a market feasible. To “repeal Obamacare” is to segregate sick people from healthy people, so that the healthy are not subsidizing the sick.
It turns out, most people don’t really want to do this. Which is why, in each chamber, when the conservative bloc would put forth a version of an amendment that would truly “repeal Obamacare,” it was met with a revolt from the rest of the party.
In the House, the Freedom Caucus pushed to relax protections for those with specific health needs or pre-existing conditions in order to lower premiums for those without them. The rest of the party revolted, which led to the bill’s initial failure in March. After New Jersey Rep. Tom MacArthur—not an ideological conservative but someone who decided for whatever reason that it would be fun to bail out the Freedom Caucus—introduced an amendment giving states authority to let insurers set premiums according to health status, nearly all of the Freedom Caucus came on board. Leaders were able to drag enough other vulnerable members kicking and screaming to “yes” by throwing a superficial sum at the problems the MacArthur amendment would create. Many of those vulnerable members knew that the vote would endanger them in 2018 but went along because they were told the Senate would fix the bill. In other words, the Senate might opt not to undermine as many of Obamacare’s protections, which are popular.
But in the Senate, Lee and Cruz pushed for an amendment that would weaken Obamacare’s protections by allowing insurers to sell plans that didn’t have to operate under those protections. This spooked the conservatives’ colleagues. Senate Majority Leader Mitch McConnell acceded at first only to a watered-down version of the amendment. It would have allowed insurers to sell plans that didn’t comply with many of Obamacare’s regulations so long as they also sold those that did. One of the Obamacare requirements the amendment kept on the books, though, was the single risk pool rule, which barred insurers from segmenting sick and healthy pools when setting premiums. By preserving this—which, in the context of the rest of the bill, likely would have proven unworkable—leaders were offering moderates and vulnerable members a fig leaf to combat arguments that they were voting to erode protections for those with pre-existing conditions. Those protections are popular. They’re the core of Obamacare. But Lee ended up shivving the Senate repeal-and-replace bill over the preservation of this single risk pool requirement and endured his fair share of potshots from Republican senators who believed he was asking for too much.
Was he? Not if you believe in repealing Obamacare, as just about all of these Republicans said they did for four consecutive election cycles. If they really meant that they wanted to repeal Obamacare, they would have been eager to eliminate the single risk pool rule. They would have been eager to let healthier people have a risk pool to themselves and to allow insurers to reject those with pre-existing conditions. This is what it means to “repeal Obamacare.”
In the end, most Republicans voted to repeal Obamacare, but only a few of them had their hearts in it. Many of them are and will be privately thanking Sens. Susan Collins, Lisa Murkowski, and John McCain for falling on the grenade, even if it’s embarrassing for the party in the moment. Seven years of opportunistic, cynical campaigning about how repealing Obamacare would solve all of the country’s health care woes nearly led the party to enact catastrophically unpopular policy to make good on a lie. They should be grateful to get off so easy.