Politics

Evan Horowitz | Quick Study

Why did the Obamacare repeal fail?

House Speaker Paul Ryan.

Cliff Owen/Associated Press

House Speaker Paul Ryan.

After years of promises, months of planning, and weeks of legislative wrangling, the Republican effort to repeal-and-replace Obamacare seems suddenly dead.

Republicans struggled to find consensus on what the post-Obamacare health insurance market should look like, and Friday’s last ditch, make-or-break push failed for the most basic democratic reason: they didn’t have the votes.

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This doesn’t mean the future of Obamacare is secure. There’s a lot the Trump administration can still do to tweak the regulations undergirding current law — including neutering the much-hated individual mandate by refusing to enforce any penalties — but the basic structure will remain in place: subsidies for the poor, no ban on pre-existing conditions, and strict requirements for the kinds of plans insurance companies can offer.

Before we look too far ahead, though, it’s worth pausing over the stunning question of how Republicans ended up in this situation: Unable to muster enough support — within their own party — to fulfill their oft-repeated pledge to repeal Obamacare.

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Here’s a rundown of the forces working against them, and their failed effort to outrun criticism.

The promise

Repealing and replacing Obamacare has been a top Republican priority for the better part of a decade. On multiple occasions, House Republicans actually voted for repeal — only to be overruled by the Senate or by President Obama.

With Republicans having taken control of the presidency and both branches of Congress, you might have thought it would be easy for them to finally pass their dream health care bill. But it wasn’t. While the party was united by a widely shared commitment to eliminate Obamacare, it couldn’t settle on a clear replacement.

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Paul Ryan’s proposal — the American Health Care Act (AHCA) — never drew unified support, despite the speaker’s lobbying efforts. Conservative Republicans wanted to gut Obamacare tout court; moderates wanted to maintain — or even expand — coverage, while helping the middle class deal with rising costs.

This schism is what killed Ryan’s bill. Every time he tried to win votes by placating conservatives, he lost moderates, and vice versa.

The president

Donald Trump twisted arms and wrangled votes for several weeks — even telling lawmakers a “no” vote would cause them to lose their seats. But by Thursday night, he was ready to force an endgame, telling Republicans it was time to make a final choice: either you’re for Obamacare repeal, or you’re against it.

Had this ultimatum succeeded, it would have been a major vindication for Trump. But it didn’t.

Still, it’s not entirely clear how much Trump really caresabout this defeat. The president’s vision for health care never really jibed with the details of Ryan’s bill. On the campaign trail, he talked about making insurance coverage better, broader, more comprehensive. Ryan’s bill didn’t do any of that, it cut subsidies and eliminated insurance for tens of millions.

The popularity

It’s hard to exaggerate just how unpopular the AHCA really was — at least, the versions that have been revealed so far.

The bill drew opposition from all sides: liberals who worried that millions would lose insurance, conservatives opposed to government subsidies, public interest groups who noted the rising cost to seniors and the poor, and hospitals who feared they’d once again be forced to absorb the cost of caring for the uninsured.

Nor did the bill fare better with the general public. A Quinnipiac poll this week showed that only 17 percent of voters supported Ryan’s plan, including just 41 percent of Republicans.

Rushing this bill into law was a way of forestalling opposition, in so far as a slower, more deliberate process would have given opposing groups time to organize and lobby. But it didn’t work.

Now what?

Put all this together and you can see the bind Republicans were in. They had to choose among several bad options: breaking their promise to repeal Obamacare, defying a Republican president, or passing a deeply unpopular bill.

In the end, they let one of their top legislative priorities slip away. Obamacare is still the law of the land, and will be for the foreseeable future.

Whether this counts as a failure is a difficult question. Certainly, it’s a breach of longstanding campaign rhetoric. But it’s not clear whether it would really have been good for Republicans to pass a bill that Americans don’t like. Maybe it was better to let AHCA die before the opposition got a chance to run their ads and before Democrats got the tar they needed to besmirch Republican opponents over an unpopular bill?

Plus, the fight against Obamacare doesn’t have to end here. Trump still has a lot of latitude to interpret regulations, and he has already issued an executive order encouraging agencies to undermine the law by regulatory fiat.

If he chooses to pursue an all-out regulatory assault on Obamacare, it might be enough to break health care markets all around the country, and give Congress new urgency to find a replacement.

Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the U.S. He can be reached at evan.horowitz@globe.com. Follow him on Twitter @GlobeHorowitz
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