John McCain’s Complicated, Inscrutable Legacy on Obamacare

WASHINGTON, DC - DECEMBER 01:  U.S. Sen. John McCain (R-AZ) passes by on a wheelchair in a hallway at the Capitol December 1, 2017 in Washington, DC. Senate GOPs indicate that they have enough votes to pass the tax reform bill.  (Photo by Alex Wong/Getty Images)
The Mac. Alex Wong/Getty Images

If the eulogies piling up now are any hint, John McCain is going to be remembered, among many other things, as the unlikely savior of Obamacare. Whether the senator from Arizona entirely deserves that legacy, or would even want it, is a bit less obvious.

McCain, who died from cancer this weekend at age 81, helped rescue the Affordable Care Act twice during 2017. In July, he joined Sens. Susan Collins of Maine and Lisa Murkowski of Alaska to vote down the bare-bones, hastily thrown together piece of legislation known as “skinny repeal,” which Republican lawmakers were hoping would keep their health care push alive. The bill was supposed to be a small-bore package of things all conservatives could agree on, and GOP leaders promised that passing it would give both houses of Congress a chance to negotiate something more substantive in conference committee. But the “skinny repeal” bill also threatened to destabilize the insurance market by quashing Obamacare’s individual mandate—which required all Americans to buy coverage or pay a fine—without taking any steps to make up for its loss. McCain’s late-night thumbs down, delivered in front of a sulking Mitch McConnell, elicited a gasp from the Senate floor and brought months of frantic work by the GOP to a crashing stop.

McCain had criticized the secretive, top-down process Republicans had used to write their health care legislation. But ultimately, he seems to have voted against skinny repeal because he was worried it would actually become law. “I had campaigned on repealing and replacing Obamacare. Skinny repeal would have killed off essential provisions of Obamacare, likely causing the whole thing to collapse, and offered literally nothing with which to replace it,” he wrote in his 2018 memoir, The Restless Wave. “I feared that all the conferees would be able to do was accept the Senate bill, repealing but not replacing Obamacare and robbing millions of Americans of their health insurance.”

In September, McCain stepped up to defend Obamacare again. Republicans had begun lining up behind another repeal bill, authored by McCain’s close friend Sen. Lindsey Graham of South Carolina and Sen. Bill Cassidy of Louisiana. The legislation would have essentially taken the money Washington now spends on Obamacare and sent it back to states to set up whatever health insurance schemes they liked while gradually throttling that spending over time. It was another rush job; Republicans needed to vote on a bill before the legislative vehicle they were relying on to pass repeal with a bare majority in the Senate expired, a short window that didn’t leave much time to refine the bill. Once again, McCain said no, which, along with resistance from Murkowski and Collins, was enough to doom the effort.

This time, he chalked his opposition up solely to process. “I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate, and amendment,” McCain said in a written statement. “But that has not been the case. Instead, the specter of September 30th budget reconciliation deadline has hung over this entire process.”

Had McCain not decided to swoop in to salvage the ACA, chances are fewer writers would be earnestly referring to him today as the Senate’s last political maverick. Until his health care vote, that reputation had mostly devolved into a punchline, particularly on the left. McCain had indeed broken with the Bush administration on key issues like tax cuts and torture. But he had spent the runup to his 2008 presidential run turning himself into an increasingly conventional Republican, and he mostly stuck by his party during the Obama years. While he threw some early, headline-grabbing barbs at the Trump administration, he also didn’t do much at first to stop its agenda. The giant gap between McCain’s rhetoric and actions seemingly came to a head during the health care debate in July, when, freshly diagnosed with cancer, he gave a resounding speech from the Senate floor calling on his colleagues to stop rushing through repeal and return to bipartisan, regular order. He then promptly voted to let Republicans continue along their slapdash process by supporting a motion to proceed. The New Republic spoke for many when it wrote, “John McCain just proved he is the Senate’s biggest fraud.”

Stopping Obamacare repeal showed he wasn’t pulling a fraud after all. At perhaps the most crucial possible moment, McCain had bucked his party and allowed millions of people to keep their insurance by supporting a law he had never particularly liked. It’s hard to think of a clearer example of putting principle over partisanship.

Unfortunately, the story didn’t end there. Late last year, McCain locked arms with his fellow Republicans and voted to scrap the individual mandate as part of the Republican tax bill—a move the Congressional Budget Office predicted would leave millions of Americans uninsured. This is precisely what skinny repeal would have done, too—which, again, is why McCain supposedly opposed it. The senator justified his flip-flop by calling the mandate “an onerous tax that especially harms those from low-income brackets”—which of course did little to explain why he opposed killing it before.

In his memoir, McCain seems conflicted about his role preserving the health care law. “I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” he wrote. “That had not been my goal.” Instead, McCain explains, he had hoped a more comprehensive replacement plan would emerge. Yet when it did, in the form of Graham-Cassidy, he rejected that too before eventually deciding that he was comfortable trashing Obamacare by repealing the mandate without a replacement. Perhaps he was more comfortable with the process that led to the tax law—but the two-month rush to pass the bill before the new year on a party-line vote could hardly be called regular order.

In the end, there may not be much of point in trying to explain McCain’s actions on health care. Maybe they were the product of confusion. Maybe they resulted from a change of heart about the value of insurance mandates. Maybe he just wanted to pull one more surprising stunt before going back to being a good soldier for the Republican Party or thought tax cuts were more important than health policy. No matter his rationale, his main legacy on health care may have been limiting congressional Republicans to only ending the mandate. After all, if skinny repeal had passed, House and Senate Republicans may have written a bill junking more of Obamacare or slashing significant chunks of Medicaid. In other words, he prevented his party from passing the very kind of comprehensive health care legislation he supposedly wanted. How mavericky.

Read more in Slate about John McCain.