Congressional Republicans have been unable to repeal Obamacare because the party has become split on its Medicaid expansion, creating a potentially unbridgeable gap on what a final healthcare bill should look like.
When former President Barack Obama’s signature healthcare reform law was enacted in 2010, Republicans on Capitol Hill were unanimous. They opposed expanding the reach of the government’s marquee healthcare program for the poor.
In the ensuing seven years, positions have shifted. Senate Republicans are now struggling to pass legislation that would only partially repeal the Affordable Care Act, because of internal divisions pitting Medicaid reformers against preservers of the expansion.
“That’s a fair observation,” Sen. Mike Lee of Utah, among other Republican lawmakers, told the Washington Examiner on Tuesday. Lee, a conservative with Tea Party roots, continues to favor wholesale repeal of Obamacare.
Medicaid is jointly funded by Washington and the states. Each state runs its version of the program differently but under federal guidelines. Under the Obamacare-facilitated expansion, Medicaid is available to Americans earning 138 percent of the federal poverty level. For a family of four, that’s $28,290 annually.
The ACA mandated that all states offer Medicaid to the expanded population. But soon after the law passed a group of Republican state attorneys general sued to block that portion of the law. They won at the Supreme Court, and as a result, the expansion became voluntary.
Most Republican governors declined to implement it, but several, along with all Democratic governors, did.
This week, as Senate Republicans labor to resolve sticking points with the Better Care Reconciliation Act, negotiations continue to revolve around how to bridge the divide between expansion state members opposed to Medicaid reductions and the aggressive reformers from non-expansion states.
“Certainly a big part of the debate within the Republican conference is states that expanded, like Alaska, and states that didn’t,” Sen. Dan Sullivan, R-Alaska, said.
President Trump has been very helpful in mediating the policy disputes, which unfolded similarly in the House, although Republicans there eventually compromised among themselves and passed the American Health Care Act.
At times, Trump has sided with centrist Republicans and urged them to pass a generous bill with more heart. At other times, the president has joined with conservatives in demanding a broader repeal of the Obamacare regulatory regime.
Trump’s indecisiveness on healthcare in some ways mirrors the contradiction facing the GOP base in the Heartland — white, blue collar and middle class — that helped elect him last year.
Many rely on the Medicaid expansion for healthcare, as do their friends and relatives who suffer from opioid abuse. In rural areas, the Medicaid expansion is all that’s keeping the lights on at the local hospital. And yet, the voters there would prefer private insurance and tend to strongly favor repealing Obamacare.
“They don’t support the expansion of the welfare state, even if they have to use it,” a Republican strategist said. “They don’t want to be on Medicaid.”
Especially after seven years of promising to repeal Obamacare, pressure from the grassroots should be impetus enough for Republicans in Congress to send legislation to Trump’s desk. But it’s not that simple.
Democrats are unified in their opposition to the House GOP’s AHCA, and the proposal now before the Senate.
Republicans are keenly aware of how they profited from the public’s dissatisfaction with Obamacare, passed with only Democratic votes, in two midterm elections. They worry that their own voters, those on Medicaid and others, might reject their health care fix and punish them in 2018.
That anxiety is apparent as some Republicans, like Sen. John Kennedy of Louisiana, call for a vote on repealing the ACA. He insists that anything is better than the status quo, but won’t commit to supporting the existing bill.
Trump won Louisiana in 2016 with 58 percent of the vote. But a year earlier, Democrat John Bel Edwards won the governor’s mansion in an upset, with about 55 percent. He proceeded to implement Medicaid expansion, rejected by his predecessor, Republican Bobby Jindal.
“What this is all about is trying to make adult decisions on the allocation of scarce resources,” said Kennedy, who like his colleague from Louisiana, Republican Sen. Bill Cassidy, is staunchly pro-repeal but vague on BCRA. “I haven’t made a decision on the bill.”
