How the GOP Sold the Base a Bill of Goods on Health Care

As Republican leadership continues to cajole GOP senators to back their health care bill, one thing is becoming clear: The original sin of the Republican health care plan was pretending you could repeal and replace Obamacare with fewer than 60 votes. This created unrealistic expectations that guaranteed an anti-climactic resolution.

Republicans are currently paying the price for this—and (whether or not the Senate bill passes) will continue to do so in the foreseeable future.

It’s important to understand the series of events that led us to this moment. Falling eight votes short of a filibuster-proof Senate majority after the 2016 elections, Republicans turned to budget reconciliation—a legislative process not subject to the Senate filibuster that allows Congress to make adjustments to budget-related items.

Using reconciliation would theoretically allow them to pass a health care bill with just 50 Republican votes (and Vice President Mike Pence as the tiebreaker). It was supposed to be quick and dirty. A surgical strike. In and out. A shortcut—a quick fix. Getting health care out of the way would also lower the tax revenue baseline, thereby making it easier to tackle tax reform (something they really wanted to do) in the next fiscal year.

This plan reeked of shrewdness and smarts, but it was too cute by half. Part of the problem is that reconciliation—meant to make this process quick and easy—actually made it somewhat pointless.

Case in point: If you are a conservative, you want to fully repeal the Affordable Care Act. Rip it out, root and branch. This requires uprooting the architecture of Obamacare and then replacing it with a free-market alternative.

Remember how the Trump administration talked about a three-pronged approach to repealing and replacing Obamacare? That’s because, even when they thought passing a health care bill might be a breeze, reconciliation rules limited the extent to which Republicans could overhaul the health care system.

Actually, this is a matter of dispute, and the GOP’s refusal to test this consensus about the limitations of what is known as the “Byrd rule” might turn out to be pivotal. For months now, conservatives like Sen. Ted Cruz have been pointing out that the presiding officer of the Senate (in this case, Vice President Mike Pence) gets to decide what is allowable for reconciliation; the parliamentarian, they insist, merely advises.

As conservative journalist and health care wonk Philip Klein tells me: “Senate Majority Leader Mitch McConnell, fearing that disregarding the advice of the parliamentarian would be the equivalent of a nuclear option to end the filibuster, has resisted the idea that Pence could more generously interpret reconciliation rules.” The success of health care might hinge on McConnell’s decision not to buck the system.

Regardless, Republicans crafted their bills operating under the assumption that they must comply with the parliamentarian’s interpretation. As a result of this path, conservatives in the Senate are now being asked to support a bill that does not fully repeal and replace Obamacare, does not uproot the basic architecture of Obamacare, and has been described as Obamacare Lite.

In hindsight, the decision to change one-sixth of the U.S. economy via a party-line vote seems imprudent. But lacking a 60-vote majority in the Senate, the alternative was even less tenable.

“The base would have rebelled at a bipartisan process,” says conservative health care expert Avik Roy, “because you wouldn’t be able to achieve something called ‘repeal’ under a bipartisan process. But as the wholly partisan process showed, full repeal wasn’t in the cards anyway, because you can’t achieve full repeal through reconciliation. Unfortunately I think they had to go this route to show the base that.”

Philip Klein agreed. “Obviously, reconciliation is a sub-optimal way to craft healthcare policy, but Republicans had no choice. Otherwise, Republicans would need 60 votes to overcome a filibuster.” Klein noted that “gaining eight Democratic votes for anything that reduces the burden of government and moves healthcare policy in a more market-oriented direction is just a pipe dream.”

Attempting to pass health care reform without either 60 votes or via the reconciliation process would have been a bipartisan affair. It’s possible it might have resulted in a broad consensus (propositional) rather than merely hoping to pass something—anything—to replace Obamacare (oppositional). It might have fixed some of the problems plaguing Americans, but it wouldn’t have repealed Obamacare, and it would have rightly been seen as a stab in the back by conservative activists. But the point of this is that changing things is incredibly hard, and as I wrote back in January, a salutary outcome (again, regardless of whether Republicans pass a bill) was almost doomed from almost the beginning.

Understanding this story will not satisfy conservative voters. They were told that Obamacare would be repealed when Republicans took over Congress. Then, they were told they would need a president. Now, I’m telling them that—to actually do it right—you would need 60 conservative votes in the Senate. This sounds A) impossible (it’s ambitious enough to imagine electing 60 Republicans, but what are the odds of getting 60 conservative senators who vote like Ted Cruz and Mike Lee?), and B) unacceptable (this is the third time we have moved the bar on the base voters).

Remember, it took Democrats generations to get the individual mandate (which, in fairness, would be repealed by the Senate bill), and that only happened because Democrats had an amazing moment where the stars aligned and they had a super majority and a president. They also had a willingness to expend political capital and make major sacrifices to get it done. Democrats lost Congress, but at least they finally passed their bill. Are Republicans willing to make the same sacrifice—just to end up with Obamacare Lite?