Like millions of others, I was hugely relieved to get the news early Friday morning that three Republican Senators had joined 48 of their Democratic and Independent colleagues to vote down the third Republican proposal to take healthcare away from millions of people. Now’s a good time to think about how we got here and what comes next.
The Affordable Care Act
For much of 2009, Democratic members of Congress spent months negotiating with Republican colleagues and one another on the legislation that would eventually become the Patient Protect and Affordable Care Act. Over many hours of debate, hearings, and bipartisan roundtables, Democrats worked to craft something that Republicans could live with. I suspect that if Mitch McConnell hadn’t been so committed to obstructionism, at least a couple of Republicans would have voted for it.
The ACA ended up looking a lot like the Massachusetts model that then-Governor Mitt Romney successfully enacted: a combination of existing employer-sponsored insurance, government-supported coverage for low-income residents, and a regulated and subsidized private market for those who didn’t have employer-sponsored insurance or Medicaid. The much-derided individual mandate, a mechanism also supported by the conservative Heritage Foundation, was the necessary evil to avoid a death spiral in the private market – because if you don’t require people to have insurance, they’ll only get it when they’re sick or injured, and costs will quickly soar and discourage healthier people from joining the risk pool.
The ACA had flaws, and was hobbled by the Supreme Court’s decision that the Medicaid expansion should be optional. Many of the problems Republicans have pointed to over the past seven years are real: Premiums and deductibles for individual marketplace plans still strain many families’ budgets, and insurers find some markets too volatile, unpredictable, or costly, leaving some areas with few – or no – insurers offering individual plans. These are things that could be fixed, but the plans Congressional Republicans have offered would make them worse for all but the healthiest insurance purchasers. Meanwhile, the ACA success that’s arguably most important – the Medicaid expansion – is something the Republican bills would undo and exacerbate with deep cuts and fundamental alterations to Medicaid.
Republicans’ approach and the backlash
Faced with a law that already represented a compromise, and given seven years to come up with alternatives, what did Paul Ryan, Mitch McConnell, and their colleagues do? They tried to mislead the public about the ACA and about their own hastily cobbled-together bills, which primarily consisted of huge cuts to Medicaid and taxes with some ACA destruction thrown in. The Senate process represented a shocking departure from the norms that have governed that chamber: no hearings, bills crafted in secret, and text revealed mere hours before Senators were expected to vote on it. It wasn’t a process designed to legislate thoughtfully on something that accounts for one-sixth of the economy and profoundly affects all our lives – it was a process designed to get a political win before Senators could think too much about a bill’s contents.
They almost succeeded. Forty-eight Democratic and Independent Senators – including Mazie Hirono of Hawaii, who is fighting Stage 4 kidney cancer – held firm against the appalling process and bills. Republican Senators Susan Collins of Maine and Lisa Murkowski of Alaska voted against each of the destructive proposals that McConnell brought to the chamber last week in quick succession. The third proposal, the so-called “skinny” repeal, came up for a vote in the early hours of Thursday morning. Senator John McCain, who flew back to Washington after surgery for what turned out to be brain cancer, cast the third Republican vote against it.
The three Republican Senators who voted down the last Senate bill faced pressure from their colleagues, including suggestions of violence against Collins and Murkowski and implied threats that a “no” from Murkowski would results in Trump administration retaliation against Alaska. But they, along with the other Senators, also heard from many constituents whose calls, letters, office visits, marches, and rallies clearly communicated their disapproval of the Republican approach. The Capitol switchboard logged its busiest day, while regular rallies outside the Capitol featured speakers from AFSCME, Center for American Progress, Indivisible, MoveOn, Planned Parenthood, SEIU, and UltraViolet, as well as several members of Congress. Office visits from Little Lobbyists and sit-ins by ADAPT drew attention to the devastation Medicaid cuts would spell for children with complex medical needs and people with disabilities. We might never know which, if any, of those actions influenced the three Republican “no” votes in the end, but there was no way any Senator could’ve claimed to be unaware of the substantial public opposition to their destructive process and proposals.
I wrote back in March about ways Congressional Republicans and the Trump administration have been sabotaging the ACA-created private market, including by cutting open enrollment outreach and continuing to withhold payments to insurers to offset the cost-sharing reductions the ACA mandated for lower-income enrollees. The Trump administration has been making these payments on a month-to-month basis, and the absence of a firm assurance that they’ll continue is worrying to insurers (and could lead to an average 19% rise in premiums). The administration’s decision to shorten the open enrollment window, its lack of commitment to enforcing the individual mandate, and its ending of contracts for “navigator” enrollment assistance are all likely to reduce the number of people – especially young, healthy people – who buy individual plans through state marketplaces.
(And, of course, ACA repeal isn’t completely dead yet; President Trump, despite displaying no understanding of how US health coverage works, is still pushing Republican Senators to pass something.)
If Congressional Republicans are really interested in fixing the premiums and deductibles they claim to worry about so much, they have the ability to do so. They could start with holding some bipartisan meetings and really listening to the healthcare providers, patient groups, hospitals, insurers, governors, and other experts who’ve been explaining why their recent bills are recipes for public-health disaster. Once they have some proposed legislative text, they could hold hearings on it and make improvements in response to concerns people raise. In other words, they could act like thoughtful legislators who care about their constituents’ health more than about undoing a signature achievement of the previous president. There’s a glimmer of hope here: In the House, the bipartisan Problem Solvers Caucus has released a proposal to stabilize the ACA marketplaces without torpedoing the law itself.
The ACA allowed 20 million people to gain insurance and freed millions more from the fear that they could be denied health insurance or coverage of needed care based on their gender or health history. I’m more hopeful than I was a week ago that those gains will remain, but I’m still worried about what else will happen over the next several months.