Why Repeal and Replace Is Going So Badly - by Josh Marshall

By JOSH MARSHALL Published MARCH 8, 2017, 11:25 AM EDT

The outlook for the GOP leaderships' 'repeal and replace' bill looks bleak. That said, I would not underestimate the ability of GOP leaders to get their members to vote for basically anything in the crunch. Also remember that House Republicans have a 20+ vote cushion. But it's worth reviewing what I believe are three key reasons why the current legislation looks to be on life support just a day after it was released.

1: Reality. Going back seven years the Republican party has not only been committed to opposing and repealing Obamacare. It has grown to the level of almost being a core element of party ideology - not any policy on health care but opposing "Obamacare". It was the core of the 2014 election, the core of the 2012 election and a major point in the 2016 election. But while this was happening, there was a less visible but equally consequential development. The GOP largely accepted the premise of Obamacare. And by premise here I mean the premise that the people who received coverage under the Affordable Care Act should have gotten coverage and should be able to keep their coverage. This was the basis of the evolution from "repeal" to "repeal and replace" to "repeal and replace ... it with something even better."

The fact that Republican elected officials may not have really gotten religion on near-universal coverage isn't the point. They accepted the premise in their public messaging. This is why we have gone years with the GOP not being able to come up with a plan. It's not hard to find a plan. There are a million potential plans, the most simple of which is simply to repeal the ACA altogether. It's not that Republicans have been lazy or haven't focused. Coming up with a plan means squaring an impossible circle to bring together those who want a more palatable/'market based' approach to ensure coverage for roughly the same amount of people and those who want to cut the taxes Obamacare was based on and let everyone fend for themselves. In a sense it's a battle within the minds of people who pushed a strong political argument with no ability to follow through if they regained power. To the extent it is a factional contest, there are varying differences of principle, different kinds of districts and states where elected officials can or cannot give free reign to their ideology purity. But that's the gist of the problem.

There are numerous complexities to health care provision. You can save money by creating efficiencies, functioning markets, compelling everyone into the risk pools, etc. But at the end of the day, covering people, making quality health care available to millions more people costs money. It also involves regulation to avoid various sorts of adverse selection. There is no way to evade this iron law. More money means more coverage and more care. And vice versa. They haven't squared this circle because it is unsquarable. This first attempt gives everyone something to dislike. That is exacerbated by the fact that the bill is devised to serve a political goal - getting past the GOP's 'repeal and replace' crisis - rather than a policy goal - insuring people. Because of that the details don't really add up. Not only is it skimpy in what it provides, while maintaining the 'entitlement' elements which piss off the far-right, it is such a hodgepodge that it probably won't work in structural terms. You can say you'll continue the ban denial of coverage for pre-existing conditions. But you need to have enough money in the system to make that viable for for-profit insurance providers.

more
http://talkingpointsmemo.com/edblog/why-repeal-and-replace-is-going-so-badly