The Health 202: Health care failed because GOP divide is too large to bridge

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The curtain has closed on Act Two of the Senate’s unfolding drama to pass a bill reshaping the Affordable Care Act, with abrupt and startling defections last night by two conservative senators, Mike Lee of Nevada and Jerry Moran of Kansas. But stay in your seats — GOP leaders are working backstage on Act Three.

It appears the current version of the GOP’s “Better Care Reconciliation Act” is dead for the time being, with four total Republican senators now refusing to even bring it to the floor for debate (Sens. Rand Paul of Kentucky and Susan Collins of Maine are opposing were the first to defect). The additional changes Majority Leader Mitch McConnell, R-Ky., added last week weren’t enough to appease Lee and Moran, who issued critical statements last night saying the current bill still leaves too much of the law in place and doesn’t do nearly enough to bring down health-care costs.

“In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle class families; nor does it create enough free space from the most costly Obamacare regulations,” Lee said. Moran blasted the entire, closed-door approach toward writing the bill, calling for Republicans to “start fresh with an open legislative process.”

Trump — and some Republicans — are likely to blame Democrats. But the truth is that replacing even parts of Obamacare is too wide a legislative chasm for the party’s conservative and moderate wings to bridge. Republicans suffer from deep divides over how much to spend on Medicaid, how to approach the individual insurance market and how much of the ACA’s elements to keep in place. For all their years of campaign vows to repeal and replace Obamacare, they never put in the hard work of crafting consensus legislation to replace it.

But McConnell is bound and determined to hold a vote on the measure — even if it suffers an embarrassingly bad defeat. Monday night, the majority leader said the Senate will still vote on starting debate on his bill “in the coming days.” But once the bill is on the floor, the idea is to then replace it with another, repeal-only measure Congress passed back in 2015. President Obama vetoed that bill, but Republicans had passed it as a sort of exercise in how they would eliminate the ACA should they eventually win the White House.

President Donald Trump and conservatives in the House are jumping on the repeal-only bandwagon fast. It’s what many of them wanted all along, after all.

Passing a repeal-only bill represents a return to Republicans’ original plan early this year. Ditching big parts of the ACA — and replacing it later — was their initial scheme as they considered how to fulfill their seven-year campaign promise to get rid of Obama’s signature domestic achievement. They only decided to couple it with replacement elements when senators began expressing concerns about disrupting the markets and leaving millions of Americans without health coverage.

Here’s how the next few weeks are likely to play out. McConnell plans to hold a vote to start debate on the current health-care bill, essentially daring conservatives to vote against an Obamacare repeal bill. If that fails, McConnell can say he at least tried. If a majority of senators vote to start debate — which would require two of the four defectors to come back on board — the bill would then be replaced with the 2015 Obamacare repeal bill that nearly every Republican is on record voting to support. That bill would have gotten rid of Obamacare’s individual and employer mandates, its taxes, its subsidies and its Medicaid expansion.

There’s something interesting about that 2015 bill, though. It would actually repeal less of the ACA than McConnell’s bill. Republicans also used the budget reconciliation process to pass that bill, so they’d only need 50 votes in the Senate and could bypass Democrats. Because of concerns that repealing the insurance regulations would run awry of rules governing a budget bill, Republicans didn’t touch that part of the ACA in the measure.

Even so, every single Republican in the Senate at the time — with the exception of one, Collins — voted for the 2015 bill. McConnell is sure to remind them of that if he accomplishes the seemingly impossible by bringing it to the floor.

“Absolutely,” Lee spokesman Conn Carroll told me Tuesday morning, after I asked whether Lee would vote for the prior bill.

McConnell’s long game is unclear at this point. Here’s what we do know: Trying to ram a sweeping health-care bill through the legislative process with the help of Republicans who don’t even agree in the first place on what the U.S. health-care system should look like isn’t a winner. In fact, it’s a recipe for disaster, as the majority leader has learned. Especially when you tack on deep cuts to Medicaid spending, which is something that doesn’t play well with many voters or some Republican governors and senators.

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