Power over Principles: The Republican "Fight" against Obamacare

The Flip Flop

Before evaluating the Republican Party's nine-year fight against Barack Obama's Patient Protection and Affordable Care Act (ACA or Obamacare), one must first realize that the Republicans were resisting legislation where the Democratic POTUS had truly tried to reach across the aisle. With healthcare reform an obvious priority and a single-payer system being fundamentally against conservative values, pre-Obama Republicans continually proposed plans that featured the vaunted "individual mandate," which required Americans to "buy in" to the health insurance market. The mandate would be the foundation for Obamacare. 

In 1989, the conservative political think tank "The Heritage Foundation" first proposed this conservative alternative  to single-payer (it's important to note that the plan does not support a mandate on employers, as ACA later would). Regarding the mandate, the plan reads: 

"Many states now require passengers in automobiles to wear seat belts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement." 

The mandate is based on two principles," they wrote. "First, that health care protection is a responsibility of individuals, not businesses. Thus to the extent that anybody should be required to provide coverage to a family, the household mandates assumes that it is the family that carries the first responsibility. Second, it assumes that there is an implicit contract between households and society, based on the notion that health insurance is not like other forms of insurance protection. If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate but society feels no obligation to repair his car. But healthcare is different. If a man is stuck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on things rather than insurance, we may be angry but we will not deny him services - even if that means more prudent citizens end up paying the tab.

"A mandate on individuals recognizes this implicit contract. Society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of care. But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself." 

This study would be the basis for future suggested legislation. If Americans were required to "buy in" to the market, health insurance reform and a privatized market could seemingly co-exist in a manner that was economically viable for all sides.  

In 1993, Republicans introduced the Health Equity and Access Reform Today Act. Aside from the aforementioned mandate, the plan called for various improvements to the current system. Among them were the offering of subsidized plans for low income Americans who didn't qualify for Medicaid, insurers were prohibited for denying access on the basis of pre-existing conditions, an easy-to-understand marketplace where Americans could compare plans, establishing state-based exchanges, and prohibiting insurers from cancelling coverage.

In 2007, Republican Governor of Massachusetts Mitt Romney introduced and later passed reforms that mirrored those of the aforementioned plans.

"Some of my libertarian friends balk at an individual mandate," he said after the bill's passage. "But is it libertarian to insist that government pick up the tab for those without insurance or means to pay? An uninsured libertarian might counter that he could refuse the free care, but under law, that is impossible -- and inhumane."

If the specific reforms mentioned in those conservative plans sound familiar, they should. All of them were included in Obama's ACA. And the individual mandate supposedly held the plan together, allowing for enough money to flow to the insurance companies to maintain their profitability. 

Naturally, when Obama decided on his healthcare plan, he was likely expecting some semblance of support from at least a few Republicans. Not so. For the right, the centrist plan of Obamacare somehow became an example of far-left politics taking over the lives of Americans. This fundamentally flawed protest would drive the party to all sorts of extremes over the years to come. 



The Fight 

Despite ACA being modeled after a multitude of Republican bills, the party would oppose the bill at every measure before, during, and after its passage. Republicans voted unanimously against ACA before it's eventual passage in the House and Senate, and arranged several legal challenges in the courts. Obamacare," as they so successfully branded the plan, was at the top-of-the-list when the Tea Party movement rose to prominence in 2010,  organizing protests in October of 2009 and March of the following year. This lead the Republicans back to a house majority in 2010. The so-called Freedom Caucus in the House continued the ideals of the Tea Party. And it would be these Republicans who would refused to appropriate any funds in the 2016 budget that included one dime going to ACA, which would subsequently lead to the government's temporary shutting down in 2015.

Anti-Obamacare protesters at a Tea Party rally in '09. The political response to the new healthcare law is largely credited with the Republicans' resurgence since Democrats' sweeping electoral victories in 2008.

Meanwhile, supposed moderate Republicans followed suit, likely fearful of being unseated by far right candidates in the primaries. 2012 presidential candidate Romney even ran on a promise to repeal on "day one," despite ACA's stark similarities to his plan in Massachusetts. 

Republicans without exception would oppose the legislation for every remaining day of Obama's presidency. House Republicans voted an astonishing 54 times to repeal, even though said repeal had no chance at getting through the Senate, which was Democratically-controlled until Obama's final two years in office. 

When the Republicans won back the senate in 2014, much of it was due to their intensive campaigning against Obamacare.  All Republican candidates called for an end to the ACA. The party spent $450 million on ads bashing Obamacare, with anti-ACA ads outnumbering pro-ACA versions by an astounding rate of 15-to-1.  Of the 66,000 ads run for Republican candidates in 2014, over 30,000 were of the anti-ACA variety. For Republicans, repealing Obamacare this was their main issue on the campaign trail.

It's worth mentioning that in an especially weak series of moves, Democratic senate candidates distanced themselves from the POTUS, and went on to suffer huge losses in the 2014 midterms. Still with both houses of congress Republican-controlled, Obama predictably proclaimed he would veto any repeal that crossed his desk.

Mixed Results

After Obamacare was implemented, even the most partisan of Democrats would have to admit that there have at least been some growing pains. 

For starters, there was the disastrous rollout in 2013, with healthcare.gov experiencing a myriad of problems ranging from technical issues with the website to under-pressure congressional Democrats looking to save face and pass alternative legislation in their respective states. In the end, ACA enrollment was extended in an effort to maximize the number of Americans buying a premium. Many cheaper plans with less coverage (these were especially popular among younger Americans) were eliminated under ACA despite Obama's infamous "if you like your plan, you can keep it" comment. Rates of uninsured Americans initially increased, although the number would plummet soon after. 

For a myriad of reasons, insurance premiums continue to rise. This resulted in many Americans ignoring the individual mandate and instead choosing to pay the cheaper tax penalty. This leaves one to wonder if the program is indeed sustainable in the long term without some serious tweaking. 

Most importantly, ACA failed in successfully cutting government's excessive healthcare spending, one of many areas where inflated spending has hamstrung the U.S. economy in the past. Although Obama exuberantly exclaimed during his final State of the Union address that "healthcare inflation had slowed," the statement was highly misleading. Obama was referring merely to a slowing of the acceleration of healthcare expenditures over past years. In the larger picture, overall costs had reached an all time high that year. In 2016, the trend Obama had lauded quickly reversed itself, as healthcare costs increased much more dramatically, this time at their highest rate since 2007. 

On the other hand, the ACA accomplished plenty of good, too, Much in part due to its subsidized premiums and Medicaid expansion, higher numbers of Americans have access to affordable healthcare. In Obama's last year in office, America reached a record low of uninsured citizens, with the number dipping below 9% for the first time in the nation's history.  

And after being branded as an unacceptable piece of legislation for so long, and Americans seemingly taking the bait at the ballot box, the tide started to turn over the last year. Perhaps worried they might lose access to their premiums under a repeal, the majority of Americans began to show their support for ACA. And they showed up in droves to recent Republican town hall meetings, expressing their disdain at the possibility of a repeal. 


Enter, Trump: "Repeal AND Replace"

In 2016, when Donald Trump ran for the Republican Nomination for president, his stance on repealing Obamacare towed the party line. But he was the first of the nominees to truly get behind a "repeal AND replace" strategy. After all, the aforementioned successes and increasing popularity of ACA put Republicans in a tough position, as a repeal would likely cause many Americans to lose their policies, potentially amounting into political suicide for Republicans across government. Despite this, the topic of replacing the law with something better was somehow not among the more prevalent conservative talking points. 

In a Sep. 2015 interview with 60 Minutes' Scott Pelley, Trump got the ball rolling when asked about his position on healthcare.

Scott Pelley: What's your plan for Obamacare?

Donald Trump: Obamacare's going to be repealed and replaced. Obamacare is a disaster if you look at what's going on with premiums where they're up 45, 50, 55 percent.

Scott Pelley: How do you fix it?

Donald Trump: There's many different ways, by the way. Everybody's got to be covered. This is an un-Republican thing for me to say because a lot of times they say, "No, no, the lower 25 percent that can't afford private." But--

Scott Pelley: Universal health care?

Donald Trump: I am going to take care of everybody. I don't care if it costs me votes or not. Everybody's going to be taken care of much better than they're taken care of now.

Scott Pelley: The uninsured person is going to be taken care of how?

Donald Trump: They're going to be taken care of. I would make a deal with existing hospitals to take care of people. And, you know what, if this is probably--

Scott Pelley: Make a deal? Who pays for it?

Donald Trump: --the government's gonna pay for it. But we're going to save so much money on the other side. But for the most it's going to be a private plan and people are going to be able to go out and negotiate great plans with lots of different competition with lots of competitors with great companies and they can have their doctors, they can have plans, they can have everything.

Later on, during one primary debate, supposed moderates and closest competitors Marco Rubio and Ted Cruz slammed Trump's position. And in an amazing moment, Cruz attacked Trump for suggesting that the government cover anyone.  

CRUZ: Did you say, if you want people to die on the streets if you don't support socialized health care, you have no heart?

TRUMP: Correct. I will not let people die on the streets—let me talk. 

CRUZ: Explain your plan, please. 

TRUMP: My plan is simple. We'll have private health care, but I will not allow people to die on the sidewalks and the streets of our country if I'm president. You may let it, and you may be fine with it— 

CRUZ: So does the government pay for everyone's health care?

TRUMP: We are going— 

CRUZ: Yes or no. 

TRUMP: Excuse me. We are going to take those people and those people are going to be serviced by doctors and hospitals. We're going to make great deals on it, but we're not going to let them die in the streets.

All of a sudden (and even though he offered no concrete idea of how his plan would work), Trump was the moderate on the debate stage. That would be the story of the entire primary, as Trump controlled the narrative on issues ranging from immigration to infrastructure. For the first time, Republicans were discussing what they would do after a repeal. Somehow, some way, it was Donald Trump who started that conversation. And also, he was the only Republican candidate willing to embrace universal health insurance with the inclusion of government assistance, as the ACA had succeeded in doing.  

The "Plan" 

After Nov. 8., the promise of every Republican to enact a "better healthcare plan" finally seemed possible. As we all know, the 2016 elections left Republicans with their largest majorities across the board since the late 1920's. The victorious Trump had promised to repeal Obamacare quickly. Republicans were wholly behind him.

And yet, when it came time to cash in on their seven-year promise, the supposedly unified Republicans splintered.

The 56-page bill known as the American Health Care Act (AHCA) was lauded by Trump and House Speaker Paul Ryan, who had made the repeal of ACA one of his greatest promises when assuming the speaker's role. Trump insisted the plan would  "expand choice, increase access, lower costs, and at the same time, provide better healthcare."  Press secretary Sean Spicer comically boasted about the length of the "succinct" plan compared to the encyclopedia-sized ACA.

The bill of course eliminated the Republicans "hated" individual mandate. But AHCA went much further. It also included the replacement of ACA's subsidies with refundable tax credits. The credits were capped at $4,000, regardless of income. The act also looked to cut Medicaid funding, allowing a set amount of funding per person. By 2026, many states' funding for the program was expected to decline by nearly 40%. Republicans also removed a provision from ACA that placed a cap on how much insurance companies could charge older Americans. Meantime, the money saved from the elimination of costly subsidies and Medicaid went to reversing a tax imposed by the ACA on wealthy Americans and medical companies. The bill also retained some of ACA's features, such as the prohibition of excluding customers based on pre-existing conditions, and restricting the insurance companies' ability to cancel plans. 

The Republicans had their bill. But they had a problem. Not a single expert worth their salt would support their legislation. Experts from across the aisle expressed their disdain, The main problem with the bill was it would have the exact opposite impact of Trump's previous musings that "everyone must be covered." There was disagreement over what exactly the problems of the bill were, but everyone was reaching the same conclusion - AHCA would fail at cutting costs, reducing premiums, and would see the rate of uninsured Americans skyrocket. 

In the end, every single analysis of AHCA revealed that numerous Americans would no longer be able to afford health insurance. The non-partisan Congressional Budget Office (CBO) concluded that 14 million Americans would lose insurance by next year, with that number set to double by 2026. As for those tax credits, experts of all political ideologies agreed that capping them at $4,000 was simply not realistic for a large number of Americans, who would still not be able to afford insurance even with the credit. 

Simply put, virtually no one could get behind the AHCA. Not even the House Republicans who had put so much time and effort into repealing the law in the first place. The Freedom Caucus railed against the bill for its inclusion of essential health benefits, a mandate in ACA requiring insurance companies cover ten essential aspects of healthcare including care at the ER, prescription drug coverage, and maternity and newborn care. Moderate Republicans were more concerned with the potential widespread losses in coverage, as well as the bill's lack of economic functionality. 

Had the bill somehow passed the House, the Senate seemed an almost impossible task. Even far-right GOP'ers like Oklahoma's Tom Cotton, who in 2014 defeated incumbent Mark Pryor over a race that saw him attack his opponent for his support of ACA at every turn, was not on board.  

"What matters in long run is better, more affordable health care for Americans, NOT House leaders' arbitrary legislative calendar," the supposedly anti- ACA senator tweeted soon after the bill was introduced. 

With Democrats universally opposed to a repeal of their bill, and previously-unified Republicans in the House changing their tune after reading AHCA, Ryan removed the bill from the agenda just hours before a vote, with the speaker realizing that there was no chance of forcing his bill through the House. 

Republicans On Healthcare: Obstruction > Governing


If you for one second thought that congressional Republicans wanted to repeal ACA due to "conservative principles," their disaster of a plan to replace the bill confirms otherwise. Over the last eight years, the Republicans voted countless times to repeal ACA, spent hundreds of millions on campaign ads against the law, and gained countless seats in the process. When they had the power to actually do what they had promised, they floundered miserably. 

The fact that there was no talk of a "replacement" until the unpredictable emergence of Donald Trump speaks volumes. Clearly, the Republicans had not even considered what would happen next after repealing ACA, completely comfortable with the chaos that would ensue after a full repeal. 

The Republicans' actual response to "dreaded Obamacare" was so pathetically putrid, it couldn't pass the same chamber that voted unanimously to repeal the law time after time. On top of that, the legislation was flawed in such a widespread manner, it was Republicans from across today's conservative spectrum that took umbrage with the bill. 

So, if the plan was so bad, what was the end-game in this long battle? We know from the fundamentally flawed AHCA that actual healthcare reform was certainly not the target. We know that talk of replacing ACA was not a topic of discussion until Trump. And most importantly, we knew that any full repeal of ACA would cause chaos in the markets and most especially for low income families who would no longer have access to insurance. Clearly, actual reform was not the goal of these Republicans. But were their actual intentions? There can only be one explanation - those 54 "symbolic" votes were not a protest of the ACA, they were a protest of Barack Obama's as President. Republicans were not against this version of healthcare reform on principle. They were against it because it came from the desk of a president whom they would resist at every turn during his two terms, with their vitriolic and sustained response to ACA being perhaps the best example of such behavior.

When all was said and done, current House Speaker Paul Ryan stood before the press, surely embarrassed at his plan's failure. Ryan did a decent job of playing politics for the most part. But one of his statements in particular stood out.

“We were a 10-year opposition party, where being against things was easy to do,” he said. “You just had to be against it. Now, in three months’ time, we tried to go to a governing party where we actually had to get 216 people to agree with each other on how we do things.” 

Ryan's admission that his party was committed to opposing legislation proposed by Obama and Democrats is telling. Indeed, for eight years the Republicans were essentially a protest party, spending almost all of their time and energy opposing the other side of the aisle, rather than looking to govern through any semblance of compromise. 

But Ryan's next line is less clear. As he says,  his party do seemingly have a lot to learn. Such learning will be paramount when it comes to leading the way for much-needed legislative reform on taxes, immigration, infrastructure, and much more. But does the Republicans' putrid AHCA show they are putting forth a valiant effort to govern on behalf of their constituents? Or does the bill's failure indicate a larger, much scarier question - do Republicans even care to govern with most Americans' best interests at heart in the first place? If healthcare reform was any indication, it's clearly the latter.