Democracy in America | No deal Donald

Republicans pull their health-care bill

Despite lobbying by Donald Trump, Republicans in Congress failed to repeal Obamacare

By LEXINGTON | WASHINGTON, DC

“WE are going to be living with Obamacare for the foreseeable future.” With those words the Speaker of the House of Representatives, Paul Ryan, admitted that Republicans in Congress and President Donald Trump—proud author of “The Art of the Deal”—have failed their first big test as a governing party.

For seven years Republicans have run against Obamacare, also known as the Affordable Care Act (ACA), calling it socialism, a government power-grab and accusing the law of instituting “death panels” that could deny older Americans care by bureaucratic fiat. When Barack Obama was still in the White House and wielded the veto pen of a president, House Republicans voted more than 50 times to repeal the ACA, knowing that these were empty show votes.

On taking power in January Republicans announced that their first priority was a law repealing as much of the ACA as possible, using fast-track rules that apply to certain sorts of budget bills, with some replacement elements to follow in two further stages. The repeal bill was rushed through committees and readied for a vote, though it was far from clear that it had the numbers to pass. In a signature move from Mr Trump’s business career, he announced this week that he was ready to walk away from negotiations with Congress, and that the House had to vote on the bill by the end of March 24th. But at teatime on that Friday an unhappy Mr Ryan announced that too many Republican members of Congress were opposed, and that he had told Mr Trump that pulling the bill was “the best thing to do.”

The failure is both spectacular and exposes the deep, unresolved tensions between Mr Trump and the fractious Republican Party that he conquered in 2016 but that he does not fully lead.

A defensive Mr Trump proved wholly unwilling to accept that, as president with a unified Republican Congress just up Pennsylvania Avenue on Capitol Hill, he owns everything that now happens in American politics, as far as voters are concerned.

Rather than address the disunity among Republican members of the House, the president groused in a brief appearance in the Oval Office that Democrats had refused to vote for his plan. “Obamacare is going to explode,” he said, sounding for all the world like a candidate on the trail, passively observing a government that is not under his control. “There is not much you can do about it.”

Mr Trump predicted that premiums were going to soar in 2017 and insurers were going to flee its individual markets. “It’s imploding, and soon will explode, and it is not going to be pretty. The Democrats don’t want to see that, so they are going to reach out,” he said. With Democrats begging to be allowed to help him with a bipartisan repeal and replacement, he was confident he would get to a “very, very good bill.”

In fact Mr Ryan’s legislation was doomed by conservative divisions, and by the impossible expectations raised by Republicans in the elections of 2010, 2012, 2014 and 2016, as they told voters that the ACA was responsible for everything that Americans dislike about health care, from rising premiums to high out-of-pocket costs—though most Americans get their insurance from their employers or from government schemes for the elderly.

The Republican plan was killed from the right by a few dozen hardline conservatives of the Freedom Caucus who called the repeal proposal “Obamacare Lite”, complaining that it left too large a role for the government and for subsidies to help people buy insurance (though in the doomed Republican effort, these subsidies took the form of tax credits). It was killed from the centre-ground by a smaller faction of moderate Republican members of Congress, often from suburban districts, who worried about calculations by the Congressional Budget Office (CBO), an agency that “scores” proposed laws for their costs and effects, that Mr Ryan’s plan for scrapping the ACA would leave an extra 24m Americans without health insurance by 2026.

Opinion polls showing that the public opposed the Republican replacement by large margins did not help. One problem exposed by this fiasco is that when Mr Trump and congressional Republicans denounced the ACA as a “disaster” that hurts Americans, they had very different motives. Conservatives in the House sincerely disapprove of the federal government’s large role in Obamacare. They dislike the fact that the ACA banned the cheap and skimpy insurance policies that were common before 2009. The ACA set 10 essential provisions that every insurance policy must cover, from maternity care to mental health treatment. It allowed young people to stay on their parents’ insurance until they are 26, and banned discrimination against those with pre-existing conditions. The right also loathed the fact that the ACA obliged all Americans to buy insurance or pay a fine—a clause designed to offset the costs to insurers of covering sicker customers with pre-existing conditions. Those new rules have contributed to higher premiums, it is true. Defenders of Obamacare retort that pre-ACA policies were not worth buying.

To placate the right, last-minute changes were made to the Republican repeal plan, stripping out those minimum standards for health policies. But that merely made the bill harder for moderates to accept.

Republicans in the Senate never even got a chance to vote on this new repeal bill, but many would have opposed it. The ACA affects people who buy insurance on the individual markets, and also greatly expands the number of the poor and disabled who are covered by the Medicaid scheme, by offering federal dollars to states which choose to cover low-income working families. Republican senators from states that chose Medicaid expansion face attack ads accusing them of throwing their own constituents off their insurance.

Mr Trump’s motives for attacking Obamacare were simpler and much less ideological. He does not share the Republican Party consensus view that health care is as much a privilege as a right, and that—to offer an analogy—if Americans want to buy cheap cars with no seatbelts or air bags or mounting points for child seats, that should be their right, without the federal government bossing them into buying more expensive rides.

On the campaign trail and as president Mr Trump attacked the ACA as the most horrible bill ever passed in the same way that he called Hillary Clinton the most corrupt politician ever. It was an applause line that chimed with the gut instincts of his core voters, and the details could not matter less.

Mr Trump is not a man interested in policy, he is a man interested in pleasing customers and voters by telling them what they want to hear. So he said that the ACA was hurting them but that he would pass a new law that would be “terrific”, covering more people, with more generous insurance, and for less cost.

That was both an impossible promise and clashed with his own party’s ambitions. He ended up trapped into backing a bill that, according to the CBO, would help the young and healthy and send costs sky-rocketing for some of Mr Trump’s most loyal supporters, starting with the old and those in rural areas.

What happens next is a mystery. Mr Ryan and Mr Trump both insist that the ACA is entering a death spiral. But Mr Trump also suggested that he has no intention of returning to the subject until Democrats are willing to join him in a bipartisan solution. It is hard to see how any fix for Obamacare acceptable to Democrats will please the hardline conservatives who killed this repeal attempt.

Mr Ryan blamed the defeat on “growing pains”, as members of Congress who have only ever known opposition adjust to life in government. There is something to that. But something simpler has been exposed. Mr Trump won office by promising things that he cannot deliver and that a blocking minority of his own party in Congress do not want to deliver. That is not growing pains but an absence of grown-up leadership.

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