A long, long time ago—like eight or nine years—Democrats had a rare opportunity that comes along once a generation in politics: They could do something. After winning the House, the Senate, and the White House, the party set out reforming the American healthcare system, which was notoriously complicated, inefficient, and cruel. After months of heated debate and compromise between liberals who wanted government-provided health insurance and moderates who wanted something less drastic, the Affordable Care Act, a.k.a. Obamacare, became law.
The ACA expanded Medicaid to a larger number of people and incentivized those too wealthy to qualify for Medicaid to purchase insurance by way of a set of penalties and subsidies. It failed to satisfy left-wing members of Congress like Bernie Sanders, who wanted "Medicaid for all"; Republicans uniformly opposed it from the beginning; it pissed off enough voters that Democrats immediately lost control of the House; it narrowly avoided being dismantled by the Supreme Court; the website it created was a clusterfuck; some of its state insurance marketplaces have been struggling; experts still debate its economic impact. It was an enormously complicated piece of legislation, in other words, that fell short in many respects—and yet it did succeed in giving millions of people health insurance, mostly through Medicaid.
With Donald Trump and the Republicans sweeping the 2016 elections, they have a similar chance to do something big, namely turn their long-held promise of repealing and replacing the ACA into concrete action. The most significant move of the repeal effort came Monday, when House Republicans, led by Speaker Paul Ryan, released a bill that officially outlined an ACA replacement. Like the ACA, the new bill—called the American Health Care Act, or AHCA—is an attempt at doing a whole lot of things at once. It gets rid of most of the ACA's unpopular features, halts the Medicaid expansion (after 2019), and lets insurers charge old people more than they currently can, among other things. It also appears to be an attempt to craft something that can pass the Senate through "reconciliation," a process that requires 50 votes rather than 60 and is intended to be used for measures relating to revenue.
It has the support of some Republican leaders, including President Donald Trump, but everyone else seems to hate it with a passion. Here's an incomplete guide to the who and why:
Obviously, everyone on the left opposes a bill that strips away benefits and protections from people. The ACA was uniformly denounced by Republicans, so Democrats have been doing the same thing to its proposed replacement. Even those who criticized the ACA as being insufficiently socialist don't want to see it struck down.
The ACHA would also defund Planned Parenthood for a year, so naturally the women's healthcare organization is against it.
Conservative Think Tanks
But the really bad sign for the bill is that conservatives have problems with the ACHA, too, albeit for opposite reasons than Democrats. The bill would keep the government involved in healthcare to an unacceptable extent, say groups like the Heritage Foundation and the Club for Growth. "Obamacare Lite" is the moniker that appears to be sticking to the ACHA. That's not a compliment.
The Koch Brothers
In that roster of conservative groups opposed to the ACHA are those backed by the anti-regulation, anti-tax Koch brothers, who have no problem throwing around the apocalyptic rhetoric of the Tea Party. From USA Today:
At a Capitol Hill rally Tuesday attended by about 200 Koch-aligned activists, Americans for Prosperity President Tim Phillips warned that Republicans "will have the shortest-lived majority in the modern era" [if] they don't toss the law on "the ash heap of history."
Right-wing healthcare wonks hate the ACA for a host of reasons, but they appear to hate the AHCA almost as much:
- "House Republican leaders sent a signal loud and clear: liberalism has already won," wrote Philip Klein, a conservative who has written extensively on healthcare for the Washington Examiner.
- "If Republicans manage to pass this, they will richly deserve it when voters blame them for the resulting havoc it will wreak in the individual market," predicted Megan McArdle in Bloomberg.
- "The GOP's real problem, in terms of passing legislation, isn't that the party can't agree on specifics, or that legislators need to bargain their way toward a compromise that gives everyone something they want," wrote Jacob Sullum in libertarian Reason. "It's that they don't agree on, or in some cases even have, basic goals when it comes to health policy."
- Finally, a National Review editorial bent over backward to praise the bill, but concluded, "The bill is a disappointment. And it is not too late to get a second opinion."
Two versions of the homepage of what is normally a very Trump-friendly media outlet:
Even before any bill was introduced to the public, AARP, the senior advocacy group with an enormous amount of political power, was gearing up to fight any Republican plan that would allow insurers to jack up rates on older people. The AHCA allows insurers to jack up rates on older people, so predictably AARP has come out against it. It even produced an ad against the "age tax" contained in the AHCA:
Meanwhile, several Republican senators have problems with the bill, too. Rand Paul and Mike Lee, both antigovernment conservatives, oppose it on the same grounds as the Freedom Caucus. Ted Cruz hasn't made up his mind about it. And Alaska senator Lisa Murkowski, a Republican moderate, has voiced concerns about any ACA replacement that doesn't leave the Medicaid expansion in place or that defunds Planned Parenthood.
At Least One Republican Governor
"Illinois won't do very well under the changes they're recommending" is how Illinois governor Bruce Rauner put his vague criticism of the ACHA. A lot of Republican governors in states that expanded Medicaid under the ACA (like Illinois did) have been nervous about a repeal that ends that expansion.
The American Hospital Association released a letter to congressional leaders Tuesday opposing the bill, presumably because fewer insured people means less revenue for hospitals.
The American College of Physicians wrote a similar letter to Congress on Tuesday, highlighting a host of concerns about sweeping changes to Medicaid and coverage requirements. UPDATE: The American Medical Association, the country's largest doctors group, announced its own opposition on Wednesday.
Conservative Republicans in the House
Adding insult to insult, even Ryan's fellow House Republicans aren't united around the bill. After a meeting Tuesday evening, the Freedom Caucus—a group of hardline conservatives in the House—was reportedly very unhappy with the ACHA, saying that the Speaker would need Democratic votes to get the bill through the House. That's not going to happen.
The ACHA plan is so hated that there's speculation that somebody as allegedly clever as Ryan would never have introduced it seriously. At the bare minimum, wouldn't he have at least consulted with the conservative groups that are tearing into the bill? Or try to get the fickle Freedom Caucus in line? Is Ryan really that dumb? Yeah, he's dumb LIKE A FOX, according to one theory:
"Ryan couldn't possibly be this inept," wrote Scott Lemieux in the Week. He didn't get his allies on board for a simple reason: He doesn't actually want any major repeal plan to pass."
Soooooo, uh, the way this theory goes is that Ryan wants to be seen making a serious attempt to repeal the ACA, but the ACA is popular enough with voters—and potential replacements are so unpopular—that making changes to the healthcare system would wreck Republicans' electoral chances. Better to do nothing loudly, then, and make sure you're reelected.
If this is what the GOP's effort to do something big looks like, getting rid of the ACA is going to be even harder than it was to set up.
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