The Twisted Logic of the Last, Desperate Attempt to Kill Obamacare

Seemingly out of nowhere, Republicans in Congress revived their obsessive quest to repeal Barack Obama's signature healthcare law this month. And once again, John McCain is set to be the one who dooms it.

This latest attempt to undo the Affordable Care Act comes in the form of what's known as the Graham-Cassidy bill, which would roll back Medicaid expansion, allocate (reduced) healthcare funding as general block grants, and end the individual mandate to have health insurance, among other steps that would functionally cripple the ACA framework. The bill would also end subsidies to help people afford private plans and make it easier for states to craft their own health insurance systems—including harsh ones that buck protections for pre-existing conditions and don't require certain basic treatments be covered.

On Monday, the Senate Finance Committee is scheduled to hold a hearing on the bill in advance of a vote expected in the chamber within the week—likely before it can be fully scored for its impact by the Congressional Budget Office. House Speaker Paul Ryan, for his part, is on board with getting bill through his chamber as it stands immediately after.

Killing the ACA has been a GOP goal for seven years, and we're now in crunch time before a September 30 deadline to use budget reconciliation rules to do so with a simple majority in the US Senate. Still, this last-ditch attempt came as something of a surprise. After their previous effort failed in July, the White House and Republican leadership seemed ready to throw in the towel. For weeks, and until as recently as this Tuesday, a bipartisan effort was underway to craft a bill to stabilize the ACA's individual marketplace, the one part of the program that is in some trouble. That approach would have also offered a few Republican reforms, like making it easier for states to design their own alternative systems. Even after a deal between President Donald Trump and the Democrats earlier this month on hurricane relief money and government funding opened up the September calendar, Republicans seemed content to focus on tax reform. As late as last Friday, bipartisan healthcare reform's prospects looked good.

All of which begs the question of why Republicans leaned away from their big tax-reform pitch to go in on another potential disaster. It's an even more confusing decision when you consider how weakly supported and fragile the Graham-Cassidy proposal is.

This general framework has actually been floating around since early summer, but failed to gain traction until now. That may be because it shares traits with previous efforts—especially the features that helped to tank them. A recent poll found that only 24 percent of Americans approve of this latest bill, which is better than the 17 percent low for the bill Republicans failed to pass in July. But this policy may actually be substantively worse for the public. "Graham-Cassidy would lead to far more disruption than any of the previous Republican plans," argued UCLA healthcare wonk Mark Peterson. "It borders on crazy."

Even as party leaders stump for this new bill, prominent Republicans and White House officials have openly expressed doubts about its prospects. With McCain having announced Friday he is firmly against the bill, the effort is dead in the water unless the bill's promoters can flip at least one of two other likely—but not confirmed—Republican no votes (Susan Collins and Rand Paul) and secure one important uncommitted vote (Lisa Murkowski) in the Senate.

Republicans appear to have taken significant flack over their August recess—not just from irate masses at town halls, but also from pals and supporters angry at their abandonment of a signature pledge. "They probably felt they had to do [something] just to firm up Republican support for Republicans," said conservative-leaning American Enterprise Institute healthcare policy researcher Joe Antos.

Trump's fixation on showing he can follow through with his promises likely egged things along, too. In a meeting on the bipartisan effort last week, he was reportedly primarily concerned with whether or not he could spin the resultant bill as repeal-and-replace to voters. (Democrats were open to letting him try, but it would have rung hollow to his base and the country in general.)

Most of the experts I've spoken to agree a bipartisan bill could have passed. But that might have read as a tacit admission that the Republicans now accept the Affordable Care Act framework. And it likely would have passed with many or mostly Democratic votes, irking the GOP's conservative wing and potentially firing up more intra-party conflict as the far-right tried to reassert itself. "There was no element of what any Republican would have called a reform," Antos said of conservative thinking on the effort.

As pressure and dissatisfaction mounted, the fully formed Graham-Cassidy proposal was still floating around, and its creators were still stumping for it. "It does hit a bunch of buttons for Republicans, but not every button for everyone, and not even all buttons for any one Republican," said Antos. Still, it worked for scheduling and it was their last chance to do anything.

Although some Republicans suspect yet another failure will hurt them even more than just moving on, the party's congressional leadership seems to think there's no downside to taking a final crack at this thing. "If they fail, it's not as good as a repeal," Antos said. "But clearly they gave it the good, old Congressional try, and that's probably not a net negative. It just might be a zero."

Besides, a miracle victory on healthcare repeal could free up funding to channel into tax reform, widening its scope, according to George Washington University health policy researcher Leighton Ku. So between Tuesday and Wednesday, the White House and Republican leaders apparently agreed that the costs of inaction were greater than those of action—and decided to throw their weight totally against bipartisanship and behind the bill.

"The desperation of the Republicans and the Trump administration is showing," Peterson told me.

This Hail Mary pass will likely remain completely up in the air until we see how Collins, Murkowski, and Paul vote—or until two of those three issue McCain-level refutations of the bill. But Collins and Murkowski's concerns from the last go-around, after which their no votes were widely applauded in the press, remain, while Paul's insistence on a more ambitious repeal than this one may be all but impossible to satisfy. And it's possible a number of other moderates and conservatives in the Senate could peel off as well, to say nothing of what could happen in the House if it tries to pass an unchanged Senate bill.

Still, deadlines matter in Congress, and "last chance to do this" messaging should keep the bulk of the Republican caucus in line. Graham and company will work what they see as the three most important swing votes as hard as they can; it's become pretty apparent that they're trying insanely hard to buy off Murkowski's vote with the prospect of extra funding for Alaska, and perhaps other sparsely populated states, slipped into the bill.

This is truly the last-gasp effort to repeal the ACA, one openly based on the political interests of one party (and Donald Trump as an individual) rather than what's good for the country. That is a deeply depressing reflection on the state of America's democracy, albeit not a surprising one.

In theory, if this bill tanks—and it probably will—bipartisan efforts could resume, and the ACA could be stabilized quickly and easily. "Republicans will own whatever comes out of this congressional session," Peterson told me. So to not be the party that blew everything up and walked away empty-handed, "there will be strong incentives to stabilize the insurance markets," he said.

That's some cold comfort in this disheartening moment for the state of America's healthcare system. But only some.

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