The Republican Health-Care Bill Is Not Designed to Actually Work
The repeal and replace bill is, finally, out.
The reviews (see this morning's Early Returns for links) from both liberals and conservatives were ... well, are you familiar with the critical reaction to "The Phantom Menace"? "Howard the Duck"? Let's just say that the enthusiasm was severely constrained.
After all, the bill will almost certainly mean fewer people are covered, with poor and lower-middle income folks losing out. So liberals aren't going to like it. Much of the structure of the Affordable Care Act remains, so small-government conservatives aren't going to like it.
In other words, it's not exactly designed to pass and become a law that actually works. Speaker Paul Ryan might get the necessary 218 Republicans to close their eyes, hold hands, and jump over a cliff in order to get the bill to the Senate. It's still unlikely that the bill will pass in the Senate, where Republicans have a much slimmer majority. And that majority includes some senators who simply won't vote for significant cuts in Medicaid, since that would mean stripping health care away from people (voters!) who currently have it. Indeed, the bill is hardly certain to pass the House, where many Republicans want (among other things) much deeper Medicaid cuts.
So, as Ezra Klein asks, what's the point? What's the problem the bill is supposed to solve?
The answer, it sure seems to me, is a political problem. Not a policy problem.
That's not to say that there are no (real, significant, and perhaps even severe) problems with health care under the Affordable Care Act. But those problems are genuinely difficult: Either the experts don't know how to fix them, or they cost too much, or they're so disruptive that the political costs are too high. Or, for Republicans, they have another problem: They look too much like fixing Obamacare, rather than getting rid of it.
So they're not really attempting to solve a policy problem. They may well, at this point, think a solution is beyond their capacity. Instead, the challenge is the political problem: The party has made repealing Obamacare its most visible campaign promise, and they realize they are on the verge of failing to do it. That's something no Republican will want to take responsibility for.
For mainstream conservatives in relatively safe Republican congressional districts -- that's the majority of the House G.O.P. conference -- this bill gives them something to support. Sure, there will be criticisms. But especially if the bill never becomes law, they can hope that most of their (Republican) constituents will trust them that it's an improvement over Obamacare. If they're more worried about a primary challenge than about losing to a Democrat, then they mainly want to avoid angering Republican voters by breaking their promise.
For many of the radicals in the House Freedom Caucus, there's a good chance this bill will work just fine, too. Their main political tactic is differentiating themselves from the mainstream of the party, in order to sell themselves as the True Conservatives among a party of weak sellouts.
For the handful of Republican moderates in the House, the bill could be trouble. Democrats could certainly run on the issue in 2018. But they too ran on replacing Obamacare, so coming up completely empty could have been a problem as well. Having an actual bill to support (or oppose) doesn't really leave them any worse off.
But the biggest pressure has been on Speaker Paul Ryan, the rest of the House Republican leadership, and the relevant committee chairs. Failing to produce any bill at all would have threatened their positions. After all, Ryan hasn't solved the problems that faced John Boehner when he resigned: Despite a comfortable Republican majority in the House, the ability of Republicans to function as a working majority is constantly threatened by a group of radicals who are willing to (or at least threaten to) work against the rest of their party.
If Ryan hadn't come up with any bill at all, he (and the rest of the leadership, and the committee chairs) would have been the obvious target for conservative media to attack for breaking the party's pledge on health care. Producing a bill -- almost any bill -- helps him avoid that.
He'll be in even better shape if he convinces his conference to pass something, no matter how many doubts they have. If he manages that, then he'll be well on his way to placing all the blame for the bill's demise on the Senate. But even if it fails to pass the House, he's no worse off than he was without a bill.
At least, that appears to be Ryan's logic, and it may well be the best choice from where he sits right now.
Granted, there were other options earlier. Ryan and Mitch McConnell didn't have to tee up health care reform as their first major bill; they could have gone for a big tax cut, which would have united Republicans and given them a bill-signing ceremony early in Donald Trump's presidency.
But they chose Obamacare first. And now, what we're seeing is very likely nothing but an exercise in blame-shifting.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
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