The first failure of the Republican Party on healthcare was immediately after they unexpectedly took control of the US government after the 2016 election. For years congressional Republicans had been passing bills that would have repealed the Affordable Care Act—a completely symbolic gesture, given that they knew Barack Obama would veto those bills. (Few even were considered by the Senate.) But once they were in power, it quickly became clear that there was not enough support among Republicans for actually doing a straightforward repeal without a replacement, which the nonpartisan Congressional Budget Office (CBO) predicted would send premiums skyrocketing and lead to 32 million more uninsured people by 2026.
So the GOP, high on power but starved of ideas, settled on legislation that didn't actually repeal the ACA but mainly cut taxes on the wealthy in exchange for rolling back Medicaid. That was the second failure of the Republican Party, as that proposal was incredibly unpopular among the public when the House passed it, and didn't get more beloved when the Senate took it up.
The third failure was directly tied to the House bill, as the proposal also broke Donald Trump's campaign promise not to cut Medicaid. That part didn't appear to bother the president himself, though, as he seemed less interested in the details of the bill he was supporting than getting some sort of legislative win. Had Trump been more conversant with the details of the bill, he could have attempted to sell it to his base. The White House legislative team—the staffers in charge of coordinating with Congress—looks bad as well, since they were apparently totally surprised by the defection of two conservative senators on Monday evening. (Republicans need 50 of their 52 senators onboard to pass a bill; they had already lost two votes before Monday night.)
Not that Trump appears to have learned much from the loss. In the wake of the bill dying, Trump took to Twitter and embraced two contradictory strategies. First, he wants Congress to repeal the ACA, then come up with a replacement later (a plan endorsed by Senate Majority Leader Mitch McConnell):
Second, Trump wants to let the ACA die—in other words, do nothing:
Then there are the likely electoral consequences related to the healthcare bill that passed the House in May. If the Senate bill is indeed dead, that House vote is a moot point—but many Republican congresspeople still voted to take health insurance away from millions, or so the campaign commercials will say when the midterms roll around. That's the fourth failure.
Number five? The Rose Garden celebration Trump held after the House vote, which now looks like a premature victory dance on the level of George W. Bush's "Mission Accomplished" moment, only Trump didn't even get to ride in a cool fighter jet.
But the largest failure of the Republican Party on healthcare stretches back to 2009. That was when the GOP—then the embattled opposition—decided not to work with Obama on his healthcare plan, which looked an awful lot like the Massachusetts system put in place by Republican Mitt Romney when he was governor. Instead of trying to compromise in good faith and advocate for tweaks in the ACA, Republicans spent long years challenging the law in court, refusing the Medicaid expansion (depriving millions of people in red states of insurance) and telling voters they had a much better plan.
Since Trump took office he has stepped up that strategy by sabotaging the individual markets Republicans say are collapsing. The administration's refusal to make subsidy payments to insurers to defray costs, along with the last six months of legislative chaos, have destabilized those markets, as insurance companies don't want to get involved in a system that might fall apart at any moment.
If Trump is prepared for more and more insurers to pull out of the markets, leaving more people without insurance, that is a failure on a moral, not a legislative scale. And if the plan now is to repeal the ACA fully in the hopes of forcing the Democrats to compromise, essentially playing chicken with the healthcare of millions of people (not to mention a huge chunk of the economy), that's less of a failure and more of a monstrosity. If the ACA collapses thanks to Trump and his Republican cronies, who do they think voters are going to blame?
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