No magic pill on repeal and replace
Let’s just say it. There is no popular replacement for the Affordable Care Act. Republicans in Congress have railed against Obamacare since its passage in 2010, and held frequent votes to repeal it in the intervening years. But after 6 months of unified control of the House, Senate, and White House, one thing is crystal clear. To pass a replacement package, they will need to do a larger version of what Democrats did in 2010: ignore the polls.
On the day Obamacare was passed, polls showed an average of 42 percent support, with 50 percent opposed. Some polls dipped as low as 30 percent in favor. One could argue the bill cost cost the Democrats a Senate seat even before it passed, when Scott Brown shocked the world by beating Martha Coakley here in Massachusetts in January 2010. Post-election polls found Bay State voters rated health care as the most important issue in deciding their vote.
Republicans are facing a similar challenge, though arguably more severe as their replacement proposals have so far been even less popular. Even in the midst of the battle to pass Obamacare, the ACA never plumbed the murky depths of fetid public distaste where the GOP replacements are currently fermenting. Polls covering various iterations of the repeal and replace proposals have found support ranging in the teens and twenties. A new poll shows Americans are ready for Congress to drop repeal altogether and move on.
But the solution is the same, if Republicans believe their proposal is either good policy or destined to become more popular. Democrats put their shoulder to the plow, and passed a bill with weak public support. And in the intervening years, the public has grown to like the bill more, especially in terms of the specifics. People have become accustomed to the new realities the bill brought about. Strong majorities like the key provisions such as coverage for pre-existing conditions, the Medicaid expansion, and others, even if they didn’t understand them at first.
If Republicans believe in their proposals, they face a similar challenge of voting for a bill which will only pay off down the road. The alternative explanation is not flattering — that they are looking for a replacement simply for a political win and to fulfill a campaign promise, though the underlying policy is bad.
Another possibility is Republicans pare back their ambitions to only repealing unpopular parts of the law with no replacement package. The so-called “skinny repeal” would do away with the mandates for individuals to buy insurance and for companies to provide insurance to their employees. (It would also repeal a tax on medical devices.) Removing these mandates may be popular in the short term, but doing so would undercut the other popular elements of the Affordable Care Act and appears likely to damage the insurance market.
Skinny repeal would deal with the tradeoff between good policy and popular policy by making policy that is both bad and likely to end up unpopular. While the individual mandate has always been the least popular part of the ACA, it is the glue that holds the rest together, as representatives of the insurance industry and a bipartisan group of governors have pointed out.
If Republicans are confident Americans will grow to love the Obamacare replacement, or that it is better for other reasons, they should take a stiff drink, put their grownup pants on, and prepare to vote for an unpopular bill. Or, if they think skinny repeal will remain popular as its effects are more broadly felt, they can vote for that too. There are plenty of instances where ignoring the polls is the right decision. Substituting elected leaders’ judgment for voters’ whims is fundamental to a representative democracy.
Voters will have their say later in 2018 and 2020, just as they did in 2010 after the ACA passed. The Democrats found themselves on the wrong side of a 63 seat swing in the House of Representatives. There were other major factors, for sure, but it’s clear reactions to health care reform played a starring role in the electoral wipeout. Democrats who voted for the ACA in 2010 lost between 5 and 15 points of support, depending on the estimate.
We don’t know if a final bill will ever take shape or what it might include. As of press time, it appears skinny repeal in the Senate may be a starting point for negotiations with the House rather than the final policy target, though even that is not clear. Whatever the final proposal, if replacing the Affordable Care Act is the chosen course, it will take backbone. There is no magic solution waiting to be discovered.
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