The contents of the emerging Senate healthcare bill are the best-kept secret in Washington. Even high-profile senators claim no knowledge of the legislative text, and it isn't even entirely clear who is writing the bill. But one thing is becoming clear: Republicans have already given up on fulfilling their seven-year promise of repealing and replacing Obamacare.
Republicans may not outright say this. In fact, if you ask them, they'll say that they're still working hard to hash out a compromise that delivers on their promise. But at this point, anything that comes out of ongoing negotiations won't be able to plausibly be described as repeal. Last December, I warned conservatives to beware of what I dubbed "RINOcare," or "Repeal In Name Only." And it's now inevitable that this is what conservatives will get – if they get anything at all.
To be clear, there are a number of true-believer conservative lawmakers in both chambers of Congress who would eagerly sign off on a bill to fully repeal Obamacare and replace it with a true free market alternative. But a critical mass of Republicans is either unwilling or unable to challenge the core elements of Obamacare.
As it stands, the House-passed healthcare bill made major concessions to Obamacare. Though true that the bill repealed much of the taxes in Obamacare, it also left the law's regulatory infrastructure intact at the national level, and only allowed for limited waivers for states from some of the law's costly mandates. It delayed until the year of the next presidential election any roll back of the law's Medicaid expansion and subsidies. And then it replaced Obamacare's tax credit subsidy scheme with a new tax credit subsidy scheme.
Though the contents of the Senate bill remain shrouded in mystery, every indication is that it will preserve even more of Obamacare than the House bill does.
Senators have balked at even the very limited regulatory waivers in the House-passed bill, and want to preserve Obamacare's provision that drives up premiums on young and healthy individuals by forcing them to pay the same price for insurance as those with much higher medical costs. They fear the backlash from repealing Obamacare's Medicaid expansion, and want to spread out the rollback of the expansion over so many years, that it raises serious doubts about whether future Congresses would actually allow repeal to be implemented. Tax credits, meanwhile, are moving much more closely toward the type of income-based subsidies that exist under Obamacare.
President Trump, meanwhile, has emboldened liberal Republicans in the Senate by calling the already watered down House bill "mean" -- and urging Senators in a meeting to pump more money into the healthcare bill.
Given the deficit reduction threshold required to pass a bill with a simple majority by employing the maneuver known as reconciliation, the only way Republicans are going to be able to find more money to pump into their healthcare bill is to scale back the repeal of Obamacare's taxes. I wouldn't be surprised, in fact, to see Republicans delay the repeal of certain Obamacare taxes until years down the line, so they can raise billions more money in the next few years to pump into the bill, while still claiming they technically voted to "repeal" the taxes.
Now, there is a legitimate argument to be had about whether certain changes are worth making, even if they stop short of a real repeal and replace bill. There are some who would argue that reforming Medicaid in a way that puts the program on a predictable growth rate in the long-run while giving more flexibility to states would be a rare chance for entitlement reform. On the other hand, a poorly-designed bill that disrupts insurance markets and fails to reduce premiums, could be wrongly seen as a failure of free market solutions, thus expediting the migration toward a single-payer system. Once a bill is released, its details will be worth debating.
But in the meantime, conservatives should come to understand that what Republicans are talking about now is really just making changes to Obamacare. They have already given up on repeal.