Elected officials don’t like to be held accountable when things go wrong, and so it is not surprising that Republican leaders are trying to avoid responsibility for failing to repeal and replace the Affordable Care Act (ACA). This was a mismanaged project from start to finish, and Republicans were never close to passing a coherent, market-driven plan for improving U.S. health care. And yet many Republicans — most notably President Trump — have settled on a version of what transpired in 2017 that puts the entire blame for the debacle on a vote cast by the late Sen. John McCain on July 28th.
It’s a convenient story, especially for the president. Sen. McCain is not around to defend himself, and putting the blame on him allows Republican leaders and the Trump administration to avoid criticism for a defining failure.
But, as others have noted, Sen. McCain wasn’t the main reason Republicans came up short on health care. Yes, he cast the deciding vote against an amendment in the Senate that put an official end to the repeal and replace effort in 2017, but by the time that vote occurred the air was already largely out of the balloon.
Here, it’s worth recounting some of the actual legislative history.
On July 25, 2017 the Senate took up a fairly serious “repeal and replace” bill, called the Better Care Reconciliation Act (BCRA). This was the amendment that Senate Majority Leader Mitch McConnell had worked on for months in his office, in an effort to unite the Senate Republican caucus around a single plan to roll back the ACA and replace it with a more market-oriented approach. Among other things, the legislation would have substantially reformed the Medicaid program. The Congressional Budget Office (CBO) estimated the BCRA would have reduced federal spending by nearly $1 trillion over a decade, but it also would have increased the number of Americans going without health insurance by a substantial number. (CBO estimated there would be an additional 22 million people going without insurance at the end of ten years, but that estimate was based on assumptions regarding the individual mandate which have since been modified.)
The BCRA provided the best opportunity for Senate Republicans to get behind a bill that, while imperfect, would have moved the country decisively away from the ACA and toward a less government-centric approach to reform. The BCRA was supported by 43 Republican Senators, including Sen. McCain. Among the Republicans who voted against the BCRA, and thus killed it, were Senators Rand Paul and Mike Lee. They viewed the legislation as insufficiently conservative. Sen. Paul, in particular, disliked the fact that the BCRA didn’t fully repeal the insurance regulations included in the ACA, and that the legislation provided a refundable tax credit to help low-income households purchase health insurance. Senators Tom Cotton and Lindsey Graham also opposed the BCRA.
After failing to pass an actual repeal and replace plan, Senate GOP leaders decided to follow the advice of some conservatives, who urged a vote on “repeal” without “replace.” They argued that it was the replace part of the BCRA that had created divisions among Republican Senators. The “partial repeal bill” was voted on in the Senate on July 26th and received 45 Republican votes. It was opposed by seven Republican Senators who objected to repealing the ACA’s coverage provisions without replacing them with an alternative subsidy structure. The conservative argument that Republicans would rally around a “repeal only” bill was proven wrong.
At that point, Senate GOP leaders were desperate to find any kind of formulation that would get 50 votes. Senator McConnell decided to make one last attempt with what became known as the “skinny repeal” amendment. That amendment was only eight pages long and included repeal of the ACA’s individual and employer mandates, a delay in the ACA’s medical device tax, defunding of Planned Parenthood, an increase in the contributions allowed to Health Savings Accounts (HSAs), and additional authority for states to implement insurance regulations that differ somewhat from the requirements of the ACA. This bill left most provisions of the ACA in place, including all of the law’s main spending provisions.
By the time the skinny repeal plan was being debated, it was clear that Senator McConnell and others wanted to pass it just so they could to go to a conference with the House (which had passed a full repeal and replace bill in May). The presumption was that, once in conference, House and Senate GOP leaders could cook up yet another version of the legislation out of public view and present it to their members in both chambers on a take-it-or-leave-it basis.
With some justification, Sen. McCain balked at how the legislative process was unfolding and chose to pull the plug on the proceedings. Even if he had gone along with the skinny repeal ploy, it is not at all clear that Senator McConnell could have gotten a more substantive compromise with the House back through the Senate later in the year. More than likely, the same forces that pushed the Senate toward a minimalist approach would have forced a House-Senate conference to do likewise.
In December 2017, Congress did include repeal of the tax penalties tied to the individual mandate as part of the tax legislation. This was another indication that the only thing Republicans could agree on was getting rid of the most unpopular provision of the ACA.
Sen. McCain contributed to the Republican failure to repeal and replace the ACA, but he was a minor player in the overall story. The basic problem was that Republicans, including Trump while he was campaigning for the presidency, did not do nearly enough in 2015 and 2016 to assemble a realistic plan that could pass in Congress and would be supported by most Americans. When they won the 2016 election, they were unprepared to take advantage of the opportunity that was in front of them. Too many Republicans assumed wrongly that their campaign slogans would translate readily into a governing agenda. When that didn’t happen, they didn’t have the knowledge base necessary to develop a more realistic approach.
With Democrats taking control of the House next year, repeal and replace is now off the table for at least two years. Republicans would be smart to regroup and work on a realistic health-care agenda that would allow the party to be more successful in 2021 than it was in 2017.
James C. Capretta is a RealClearPolicy Contributor and a resident fellow at the American Enterprise Institute.
