Today was going to be reserved for writing about the distinct differences between the ACA and the AHCA, but that issue no longer seems as clear cut as some may have hoped. The GOP has run on repealing the ACA since its inception, which helped them achieve a significant majority in the Senate, and helped them win many congressional races. However, they have put themselves in a position where they have no winning hand to play.
The problem arose as a result of their change in messaging the last few years. This played out in shifting the rhetoric from repeal Obamacare, to repeal and replace. This simple change of phrase has put them in a position that isn’t sitting well with the party as a whole.
The GOP has traditionally viewed large government programs and public safety nets in a negative light. Their values have revolved around the ideas of personal responsibility and accountability. This was the heart of their opposition to the ACA, and continues to be a loud rallying cry in some circles of the party.
What is new to this equation, is the expectation that the ACA can be repealed, but the positive effects it caused can remain in place. Elements of the voting base who cast their support behind Trump and the GOP as a whole last election, expect that the healthcare they have gained under the ACA will somehow remain intact, while costs will be reduced and compulsory parts of the ACA will be eliminated. The recent report from the Congressional Budget Office (CBO) estimating 24 million people will lose coverage, while most Americans will, in fact, deal with additional costs has been the exclamation point to the naivety behind this discussion.
The reality is, the only ways you can expand coverage and reduce the cost for the consumer, are either maintaining or increasing spending (and taxes to pay for this), forcing private enterprises to reduce costs through government intervention, or both. The math simply doesn’t allow for slogans or ideological rhetoric to stand up to scrutiny.
With this in mind, the GOP now has a crisis of identity to confront. They over promised what they could deliver in their fight against the ACA, and now they must decide what their internal priorities are. If they adhere to their traditional points of view, and that of the Freedom Caucus, they will have to gut provisions in the bill related to premium hikes for gaps in coverage, tax credits to pay for insurance, and accelerate the deadline for ending the Medicaid expansion.
However, by doing so, they will alienate the very people who voted for them, believing that the only thing plaguing the healthcare system was the ACA. Among the tens of millions who would lose coverage is their traditional base. This could result in a backlash similar to the one that swept them into power over the last few elections.
This leaves them in unfamiliar territory, pushing to provide a bill they do not agree on at the most basic levels, and fighting to revamp a bill they see as broken, instead of simply saying they do not believe the government has a role in the healthcare process as they have in the past. This situation is unwinnable for the party, and it begs the question of what they could possibly do to please their constituents in the current environment.
I don’t see a productive way forward for the party on this issue. The left will steadfastly oppose any bill they produce because the left currently is split between the ACA framework and calls for single payer, both of which are far left of the current GOP position. Which leaves only internal GOP deliberation. One side of the party is taking a more traditional approach, and trying to eliminate as much government involvement as possible, while the other has accepted government involvement as a given, and are trying to reduce costs while simultaneously maintaining or expanding coverage. The latter approach is mathematically impossible, and the traditional approach seems to have outlived its relevance with the populist who brought Trump into power.
This makes predicting what parts of the bill will change, and if it will even pass, at best a guessing game. Whatever direction they decide to take this, the analogy of a barking dog finally catching the car bumper seems the be the most accurate example of where we are at currently. Healthcare is a very complicated and much-debated issue on both sides of the aisle, and based on what we have seen so far, that isn’t going to change anytime soon.