Political Calculations Before Tomorrow’s Vote on Dismantling the Affordable Care Act
Republicans face a tough choice tomorrow: do they listen to their constituents, to their funders, to their President or to their party leaders? They have created these dilemmas for themselves by eight years of unrelenting antipathy for everything President Obama sought to do, but they are facing really tough political dilemmas nevertheless.
The Affordable Care Act is increasingly popular among those responding to public opinion pollsters and only a small fraction of the American public wants to see it repealed outright. Moreover there is strong support for the Medicaid program and its expansion and voters want to see the Exchanges and the refundable tax credits improved, not eliminated.
Republicans in Congress are split among: the moderates who want the Medicaid expansion retained and the Exchange tax credits improved, the leadership who want to freeze the growth in Medicaid spending, and re-target the tax credits away from older and poorer citizens towards higher income and younger citizens, and the Tea Party hard right that wants to eliminate the tax credits and block grant Medicaid to the states with no accountability. Unless they are all in lock step, they cannot pass the House and clearly cannot get the 51 votes they need in the Senate. Furthermore they are constrained by the rules of budget reconciliation from repealing some of the insurance reforms (for example, the ten essential health benefits) that they would like to jettison.
Twenty four million of their constituents stand to lose health coverage under the House Republican measure. Some of these constituents are very sick; others will become so in the future, and many cannot afford coverage without the Medicaid expansion and the refundable tax credits for individuals. A vote to eliminate coverage for these constituents will not be soon forgotten or forgiven in the 2018 Congressional and 2020 Presidential elections.
A majority of all Americans want to keep and build on the Affordable Care Act and only a fifth support outright repeal. However the percentages of Trump and Republican voters who want it repealed are very high, and they would be deeply disappointed if Republicans with the majority in both houses of Congress and the Presidency failed to act to replace the ACA with something more to their liking.
So what do Trump voters want? Lower out of pocket, lower drug prices and lower share of premiums that they have to pay. It has not yet fully registered with the American public that the House Republican bill offers none of these, but if passed, it will become readily apparent over the next several years to the older, the rural and those working class whites who had voted for Trump in the last election.
Political candidates are financed primarily by a small group of very wealthy individuals; the Koch brothers are emblematic of these financiers for Republican candidates. What do these funders want? They want the financing for the ACA – the higher taxes on their unearned income repealed and just as quickly as possible. The Koch brothers and their colleagues are most supportive of the hard right solutions – get the government out of health care altogether and shift into a free market system. This leaves the old, the sick and the poor without the health delivery system and the financing for their care. The Koch networks are threatening their re-election chances unless the House bill moves even further to the right.
President Trump promised lower copays, lower premiums, lowered drug costs and coverage for everyone. The House Republican bill falls well short of any of these campaign promises. At this point, he just wants a win to re-varnish his Presidency, so he can just get on with other more interesting matters to him like the large tax cuts he promised to the wealthy and corporations. He is threatening their re-election chances if the House bill fails to pass.
The party leaders face the unmistakably difficult path of pacifying both their moderates and their hard right and passing a bill, any bill. Yet they are now keenly aware that their constituency of older, white, rural working class voters will become desperately upset with the implementation of the measure they are seeking to pass so quickly, and they really have not developed workable solution to the problems they are about to create.
What’s their best political solution? Pass it in the House, kill it soundly in the Senate, then keep blaming President Obama through the 2018 Congressional elections.
What’s the right policy solution for the nation? Have the Senate build a bi-partisan consensus from the framework of the Affordable Care Act and the many interesting Republican alternatives being proffered that 1) covers everyone and 2) takes the necessary steps to seriously reduce costs while improving quality and outcomes. Most other countries have already done this; we can too, if we so choose.
Prepared by: Lucien Wulsin