In the end, it was McConnell’s expedient—but scorched-earth—approach that would undo his work. The “skinny repeal” is just not good policy, and nobody likes it. That was known before a last-minute CBO score found that the provisions repealing the Obamacare mandates while retaining its insurance regulations and tax credits would decrease coverage by 16 million while increase premiums. McConnell’s pitch was that the legislation could be amended through the reconciliation conference process, and that senators who held their noses and voted yes would get what they wanted down the road.
Essentially, as my colleague Russell Berman notes, McConnell had created a legislative process so convoluted that he ended up asking his party to vote for a law that they didn’t want to actually become law. And they almost did. If not for a late switch from Arizona Senator John McCain and Alaska Senator Lisa Murkowski’s ability to withstand withering pressure from the White House and her fellow senators, the skinny repeal would have passed, and the House would have been under no obligation whatsoever to amend it.
Although McConnell’s gambit failed, the real story might be what almost was: Faced with the real possibility of knowingly passing an Obamacare “repeal” into law that only would have destabilized markets and sloughed more people off coverage, and would have met none of their stated policy goals to reduce premiums and make insurance work better for patient, Republicans almost caved. The incentive to do anything to destroy Obamacare, even while damaging their own party, leaving millions uninsured, and “owning” the fallout, was almost too great.
With the skinny-repeal debacle, Republicans all but validated the criticisms of legions of disability activists, Planned Parenthood supporters, doctors, insurers, and people with pre-existing conditions. Their final plan did not pretend to listen to those concerns, nor when faced with difficulties, did Republican leadership seek to incorporate their concerns by bringing back regular order.
And therein lies Republicans’ central problem: Obamacare repeal is an ideological platform with little policy basis or real input from health stakeholders. It’s a reactionary position with few guiding principles. Although conservative efforts to build rational, data-driven defenses of 2017 repeal legislation have advanced as those bills matured, evidence is still thin that Republican plans can legitimately improve care for everyone, and most supporting analyses rely on fuzzy numbers and torturous logic. There are few rigorous reports that a plan resembling theirs could provide “flexibility” or “freedom” to both the sickest Americans and the healthiest.
That central problem has shifted the political landscape, as Americans’ views on health policy have changed dramatically in a short amount of time. Polling plummeted for the BCRA, to the point where only 17 percent of Americans, and only 35 percent of Republicans supported the legislation during its dying days. Meanwhile, Kaiser Family Foundation polls show support for single-payer programs growing over the past few years, even slightly among Republicans and sharply among independents. Simply, although Republicans came to power on promises to repeal Obamacare and perhaps replace it with something better, because of their own failures they no longer possess that mandate.