House Speaker Paul D. Ryan’s (R-Wis.) decision to pull legislation to reconfigure the nation’s health-care system is a major setback to President Trump and the GOP. For seven years, Republicans promised to repeal and replace Obamacare. Their failure to deliver on this promise exposes intraparty divisions that will not be easily healed.
But there is more to the story than just the GOP’s prospects as a governing majority. The failure of the American Health Care Act (AHCA) has three broader lessons as well.
Lesson No. 1: Radical changes to social welfare programs are rare.
As the political scientist Paul Pierson has argued, dismantling social programs is risky for politicians who want to be reelected. There are exceptions, of course, such as the 1996 abolition of Aid to Families With Dependent Children — a.k.a. “welfare reform.” But Obamacare is not welfare. Moreover, the AHCA’s negative impact on insurance coverage and affordability was so dramatic that House Republican leaders simply couldn’t structure the vote on the bill in a way that would protect their members from constituents’ wrath.
Many Republicans believed they could dismantle the ACA because it has not achieved the popularity of programs like Social Security. Because ACA was passed on a party-line vote, unlike Social Security in 1935 and Medicare in 1965, and because many Americans blamed the law for rising insurance premiums, Republicans thought they could push for dramatic changes.
Yet repealing and replacing the ACA was always easier said than done. In reality, the ACA had succeeded in key respects and developed a sizable constituency. The ACA helped more than 20 million Americans gain coverage. It required insurers to cover essential health benefits, such as maternity services, and protected people with preexisting health conditions from discrimination by insurance companies. When those benefits were threatened, Obamacare’s beneficiaries realized that they had a real stake in the program.
What President Barack Obama could not do — instill a sense of identity among ACA recipients — Trump and the Republican Congress may have accomplished.
Lesson No. 2: Congress (at least part of it) isn’t immune to reality.
In a world of “alternative facts,” it is easy to assume that members of Congress will just make things up to support whatever they want to do. But the failure of the AHCA shows that facts still matter.
A bit of context: In 2013, Eric Patashnik and Justin Peck conducted a survey of more than 150 policy analysts who work for government agencies, think tanks and other organizations. The survey asked them to assess Congress’s performance, and respondents generally gave Congress poor marks. For example, these experts said that Congress tends not to care about the economic efficiency of legislative proposals, discounts lessons from other nations, and struggles to confront the trade-offs inherent in legislating. (One such trade-off involving the ACA: Repealing the penalties associated with the individual mandate would likely produce an increase in the number of uninsured.)
What the experts said Congress does care about is public opinion, interest group views and the assessments of the Congressional Budget Office. And each of those was decidedly against the Republican health-care bill. Only 17 percent of the public supported it, interest groups overwhelming opposed it, and a CBO report that said that it would cause 24 million people to lose coverage by 2026 and drive up premium costs substantially for older Americans. No wonder the AHCA had difficulty gaining majority support. Congress is clearly not a research bureau, but facts still matter to many lawmakers.
Lesson No. 3: Obamacare is still vulnerable.
Republicans have conceded that the ACA will be the law of the land for the “foreseeable future.” Republicans may also face political risks if they actively seek to “explode” the individual insurance market, as Trump has promised. Republicans hope that they can blame Democrats for future problems with the ACA, but this remains to be seen.
Republicans can, however, do much to undermine the ACA, especially its health insurance exchanges, whose stability in some states is precarious. For example, the administration could use its executive authority to weaken enforcement of the individual mandate or simply pull ads to encourage people to sign up for coverage. Moreover, any such action may be harder for voters to perceive, thereby creating space for Republicans to weaken Obamacare without a clear political price.
In short, the ACA evaded repeal, but its fortunes during the Trump administration remain uncertain. How far are Republicans willing to go to undermine the ACA through administrative and legal actions? Will the ACA’s insurance exchanges stabilize or unravel in some states? Will the GOP again try to cut Medicaid to help offset tax cuts and infrastructure spending?
We don’t know the answers to those questions. What we can say is that the health care debate is not over. More conflict over the government’s role in health care lies ahead.
Eric Patashnik is director of the Public Policy Program and Professor of Political Science at Brown University.
Jonathan Oberlander is professor and chair of Social Medicine and professor of Health Policy & Management at the University of North Carolina-Chapel Hill.