After an earlier iteration of the House healthcare bill was pulled from the floor for lack of support, I excoriated Republicans, calling their failure to repeal and replace Obamacare, the "biggest broken promise in political history."
So, now that Republicans have managed to scrap together enough votes to squeeze a healthcare bill through the House, does that change what I wrote? The short answer is, it's complicated. Clearly, Republicans didn't give up on the cause of repeal and replace after just a few weeks and move on to tax reform, as President Trump and House Speaker Paul Ryan declared they were going to do after the first vote was pulled. So, that part of my criticism is no longer valid. For this, it's worth giving a lot of credit to the House Freedom Caucus, who in the past have been portrayed in saboteurs, but in this case played a productive role in keeping negotiations moving and shaping the bill – clearly stating their goals, and demonstrating a willingness to compromise to get a deal.
However, it's also worth noting that despite their best efforts, the bill still leaves a lot of Obamacare intact.
The limited waivers that were negotiated by House conservatives are unlikely to be taken up by many states, and there's room for them to be rescinded by a future Democratic administration. That means most of the country will still live under much of the regulatory structure put in place by Obamacare.
It's true that the plan does repeal nearly all of Obamacare's taxes and, if implemented as written, spends less than Obamacare on subsidizing insurance. But "if implemented" is a big if. The law delays until 2020 the planned phase out of Obamacare's subsidies and Medicaid expansion – by far the two biggest spending provisions in the law. That means these two major provisions, which currently benefit millions of people, are on track to be rescinded after the 2018 midterm elections in which Democrats are likely to make gains (at least in the House) and at the start of a presidential election year. It is not difficult to see a scenario in which Democrats, liberal Republicans, and President Trump come together to delay the implementation of this repeal, if not indefinitely.
Furthermore, as the Washington Examiner's Susan Ferrechio reports, the Senate has already decided it's not going to pick up the bill, but rather, start crafting its own. Given that Republicans can only afford to lose two votes, and that there's an intergalactic-sized ideological gulf between Sens. Rand Paul and Susan Collins, the journey to passage remains treacherous. And any bill that does pass is likely to get further watered down. This is especially true given how Trump has been such a wildcard in negotiations, vacillating between pledges to repeal and replace Obamacare to pledges to cover everybody.
During the Obamacare debate, Republicans railed against Democrats for ramming through a bill that was negotiated behind closed doors without sufficient time for debate. But in this instance, Republicans have been even worse. Both the bill itself, and all of the major amendments, were negotiated out of the public eye, with little debate over the merits. The process that produced the House bill was significantly shorter than the time frame used to produce Obamacare. And with this bill Republicans have set the precedent of passing major legislation without an updated score from the Congressional Budget Office – a decision I predict they will come to regret the next time Democrats are in power.
In an alternate universe, right now we'd be having an argument about a free market system that costs taxpayers less money, offers broader choice and lower premiums, and does not try to put government in the business of making sure everybody obtains coverage vs. a system that offers more subsidies and comprehensive insurance to individuals, while depriving younger and healthier individuals the option of less comprehensive, lower cost insurance. Healthier Americans may ultimately decide that they're willing to pay drastically higher premiums and accept less choice in exchange for helping make insurance more affordable and comprehensive for older and sicker individuals. But at least it would be an honest debate. Republicans have decided they can't win that debate, so instead they decided to embrace liberal philosophy as it pertains to broad coverage, but then try to graft it onto a plan that they can call "repeal and replace."
The result is a plan that repeals and replaces the law in a piecemeal manner and disrupts the insurance market in ways that health policy enthusiasts are still trying to figure out. Republicans are engaging in a debate over how many people they can cover and whether the bill does as much or more than Obamacare for individuals with pre-existing conditions, rather than producing a bill that would actually reduce costs. They've surrendered on philosophy and managed to vote for a politically unpopular bill anyway.