Will Republicans Ever Replace Obamacare?

The bickering has begun.

Freedom Caucus
Vice President–elect Mike Pence speaks on Capitol Hill on Wednesday in Washington. Also pictured are Sens. Cory Gardner, John Barrasso, and John Thune.

Zach Gibson/AFP/Getty Images

The question of political “ownership” over the health care system was the hot topic of Capitol Hill on Wednesday, as both President Obama and Vice President–elect Mike Pence visited members of their respective parties to game out the Obamacare repeal fight. There were a couple reasons this dominated the day’s conversation. The first is that Donald Trump tweeted about it early in the morning, so because of intractable systemic flaws in American media, politics, and culture, everyone “had” to jabber about it all day. But unlike his diatribes against random cable television hosts, magazine editors, and union reps, he hit on something important with this morning communiqué.

“Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases…… ,” he tweeted. Which party is more exposed to the fallout from repeal is an important question with the potential to dictate the fortunes of the Trump administration and the unified Republican federal government.

The answer may hinge on precisely how unified that Republican government is in writing, passing, and implementing a replacement. If GOPers want to escape the post-repeal mess they’ve committed themselves to politically, they’re going to need to show a level of unity that congressional Republicans haven’t been known for in recent years. It would be a disaster, and their disaster, if they made it to repeal but never to replace.

The side that “wins” a congressional messaging duel is usually the one with the simpler argument that cuts through the din. Democrats’ argument is blunt: If Republicans repeal the Affordable Care Act, people lose their health insurance, and market chaos ensues, Republicans will be on the hook.

Republicans also have a blunt message: Obamacare has failed, Republicans are doing the country a favor by clearing out the debris, and Democrats have an obligation to cooperate with them in crafting the replacement. Reciting Obamacare’s failure was members’ stock answer to questions of ownership throughout Wednesday.

“Failed ObamaCare disaster” was the term Trump used in his agenda-setting tweets.

“As I said today to members of the Senate, the first order of business is to repeal and replace Obamacare,” Pence said at a press conference following a lunch with GOP senators. “Obamacare has failed.”

Sen. John Barrasso, a GOP point person for repeal-and-replace efforts in the chamber, noted after the Pence meeting how unfortunate it was that President Obama was spending the day “defending a law that the American people know has failed. It’s been six years; the American people know that the health care law has failed them, for the most part.” (“For the most part” is generous: A Kaiser Family Foundation poll from early December showed that only 26 percent of the public supported full repeal of the law.)

“The chaos has been created by Obamacare,” Sen. Cory Gardner said, when asked what his response would be to Democratic charges that repeal would create chaos.

Who’s got the winning argument? Once Republicans complete the first stage of repeal, delay, and replace, which they intend to do by the end of February, this will be much easier to adjudicate: We will be able to measure what effects the move has on insurers, the insured, premiums, and the like.

Those effects are not projected to be good, and some Republicans members are beginning to show their unease.

Sen. Rand Paul on Wednesday voted against the budget resolution that begins the repeal process. His given reason was that he wasn’t happy with the spending levels it set. But he also came out this week against repealing before a replacement plan is ready.

“I think it’s imperative that Republicans do a replacement simultaneous with repeal,” Paul said on Wednesday’s Morning Joe. “If they don’t, there are many health care analysts predicting bankruptcy for insurance companies and a massive insurance company bailout within the first six months of repeal.” Sounding like one of those snooty D.C. wonks that America loves to stuff inside a locker, he explained that repealing the individual mandate while leaving guaranteed coverage for those with pre-existing conditions on the books would accelerate the problem of adverse selection and throw insurance markets into chaos.

“If Congress fails to vote on a replacement at the same time as repeal, the repealers risk assuming the blame for the continued unraveling of Obamacare,” Paul wrote in an op-ed. “For mark my words, Obamacare will continue to unravel and wreak havoc for years to come.”

Paul has not been the only Republican finding merit in Democrats’ warnings. What underlies all of it is a fear that Republicans, if they repeal before they’ve even written a replacement, will never be able to get an adequate replacement through Congress given Democratic opposition and Republican internal squabbling. One Republican member, as Talking Points Memo reported, laid out the post-repeal political landscape succinctly in a closed-door caucus meeting Wednesday morning. “You lose all leverage once you repeal this thing,” the member said. “There will be people on the left who will never help you replace it, and there will be people on the right who aren’t going to help you either. We will own this thing, and there will be consequences.”

Barring a nuking of the legislative filibuster, a replacement plan would need 60 votes in the Senate. In this Congress, at least, that requires significant Democratic support. To break Sen. Chuck Schumer’s grip over his caucus and woo the necessary red-state Democrats, Senate Republicans would have to deal. Those concessions, in turn, would turn off some conservatives in the Senate and the Freedom Caucus in the House. Keep in mind, too, that this is health care, an extremely difficult subject on which to legislate: Just because Democrats were able to pass a comprehensive health care reform law in 2010 doesn’t mean that doing it the second time will be easier.

The way the first step of the process is going doesn’t augur well for the rest of repeal, delay, and replace. This first step is, by several orders of magnitude, the easiest part: The House and Senate each need to pass a budget resolution that unlocks the reconciliation process through which repeal will take place. The Senate was able to open debate on the resolution Wednesday by one vote. Paul, channeling his inner Ted Cruz (who’s lying low these days), wasn’t content with making his case in just his own legislative body. On Thursday morning he met with the conservative House Freedom Caucus to persuade its members to block the budget resolution in its chamber. The Freedom Caucus is still mulling it over and is expected to “meet formally next week to consider an official position on the budget.”

I don’t expect the Freedom Caucus to blow up the resolution and deal the repeal effort a crushing setback in its infancy. That this is even an open question, though, doesn’t inspire a lot of confidence. It doesn’t suggest that Republicans, with no Democratic votes to help them, will be able to resolve questions about whether they want to spend large sums of money—either directly or, more likely, through tax credits—to subsidize health insurance, guarantee coverage for pre-existing conditions, or subsidize insurance companies to keep them afloat during the transition to whatever end point they’re transitioning.

The Democrats’ plan for the Affordable Care Act is not to repeal and replace it. That is the Republicans’ plan. If they get only halfway through, and the health insurance industry and those it covers all find themselves in a markedly worse situation than they would have under the status quo, that’d be a compelling case that the Republicans own the problem. That they’re the party starting to sweat is the clearest tell you can get.