Almost seven years after the passage of the Patient Protection and Affordable Care Act (a.k.a. Obamacare), the Republicans have finally released their much-anticipated replacement bill. They had been content, up until quite recently, to just use "repeal" as a rallying cry without giving a whole lot of thought to replacing Obamacare with anything, and for good reason. No matter whether you agree with them or not, you have to admit that, politically, this tactic worked wonders for them. But now that there's a Republican in the White House again, the pressure was on Paul Ryan to actually show America what Republicans would do differently than Obamacare. Late yesterday, his bill was finally publicly unveiled.
It hasn't even been 24 hours yet, and already the bill is being rhetorically torn to shreds. This would be a normal political reaction, except for the fact that the biggest pushback is coming from Republicans. Democrats are indeed denouncing the bill, but their voices aren't getting as much media coverage as the Republicans who are currently savaging their own party's bill (which, to be honest, is more interesting -- explaining the media's decision to focus on it).
What's really interesting is that the GOP opposition is simultaneously coming from two diametrically-opposed directions. There are "purist" Republicans who are now insisting that "Ryancare" (as they deride the new bill) is nothing more than "Obamacare-lite" or even "Obamacare 2.0." Some are even calling it "RINOcare" (which wins my award for the most amusing portmanteau created in the past 24 hours), combining two derogatory names conservative stalwarts hate ("Republican In Name Only" and Obamacare). But whatever they're calling the new bill, they certainly don't seem to like it much.
Then there are the "pragmatist" Republicans, who instead are arguing that the new bill is going to hurt the states (with Republican governors, even!) which adopted the Obamacare Medicaid expansion. Millions of citizens will be harmed by the new law, which makes it politically impossible to support, the pragmatists warn.
So, on one side, we've got those Republicans who are arguing that the bill is too Draconian, and then on the other side we've got Republicans who are insistent that the bill is nowhere near Draconian enough. As Donald Trump recently learned, this health care reform stuff is a lot harder than it looks!
Republicans are in a tough spot of their own making, so it's hard to feel even a little bit sorry for them. Obamacare itself was initially a conservative idea (from the Heritage Foundation), which was then tried out on a state level by a Republican governor (Romneycare), and then made as conservative as possible during its drafting, in the hopes that a few Republicans would vote for it. Hundreds of conservative amendments were added, and the hopes of progressives were dashed when not only did Democrats refuse to consider single-payer, but also went out of their way to kill any mention of a public option. It wasn't exactly creeping socialism, in other words. But because of all these legislative gymnastics, the final bill was about as conservative a plan as Democrats could come up with. Insurance companies would be reined in a bit, but would still be the only choice for most Americans. What this now means is that Republicans have very little wiggle room in their efforts to replace Obamacare. It's hard for them to get to the right of a plan that was pretty far to the right to begin with, in other words.
This is what Paul Ryan and Donald Trump and the rest of them are all beginning to realize. Ryan, after much secrecy and behind-the-scenes wheeling and dealing, finally had to put forth an actual plan on paper that the public (and the rest of Congress, for that matter) could read. Ryan and the Republican establishment are hopeful that they've struck a middle-of-the-conservative-road stance that most Republicans can eventually vote for. It's not as drastic as just repealing Obamacare and replacing it with nothing, but it's also nowhere near as comprehensive as Obamacare itself. But walking this tightrope is already causing Ryan some headaches -- and, once again, it hasn't even been 24 hours yet.
Rand Paul and the Tea Partiers in the House are incensed that the bill isn't a full and total repeal of all things Obamacare. They are backed by some pretty powerful conservative groups in this stance, who are threatening Republican politicians with a major pushback effort if they don't vote against the Ryan bill. Their cry, they've announced, will be: "Keep your promise!" The Koch brothers are already ramping this effort up, and they do indeed have a point -- a lot of Republicans got elected promising full and complete repeal, and Ryan's bill comes nowhere near to fulfilling that promise.
On the other side are Republican governors and senators from states that expanded Medicaid, who don't want to see the rug yanked out from under them. These are Republicans who, sotto voce, will actually admit the fact that Obamacare has helped millions of people, many of them living in red states. They are already coming out against Ryan's bill, because while Ryan has tried to make the process gradual, the end result is the same as just repealing the Medicaid expansion: the federal dollars these states have come to love will eventually disappear. And some Republicans are smart enough to foresee that this may wind up being a political problem for them in the very near future.
Ryan is now trapped between these mutually-exclusive factions. If he tried to placate the Tea Partiers by making his bill an even harsher return to the pre-Obamacare days, he would lose more of the centrists in his party by doing so. If he tried to make the bill more generous to gain the votes of the pragmatists, he's going to face even more fury from the purists.
It's impossible to tell, at this early date, how this is all going to play out. After all, Democrats were pretty divided on the subject for roughly a year and a half, but in the end they did manage to pass Obamacare. So it is indeed possible that Ryan is correct in hoping that Republicans will pretty much be forced into voting for the bill in the end, since it'll be the only "repeal and replace" bill they'll have the chance to vote for. Maybe they'll all get in line, as Ryan hopes.
Then again, maybe they won't. While Ryan can afford to lose a few dozen votes and still muster a majority, over in the Senate the margin's a lot thinner. The loss of three Republicans would doom any bill, and what's interesting is that there are already that many lined up on both sides of the issue. Four Republican senators (from states with Medicaid expansion in place) have already said they can't vote for the Ryan bill. Three senators (mostly led by Rand Paul) have said just as forcefully that they'll never vote for "Obamacare-lite." That leaves Mitch McConnell in a tough spot, since no Democrats are likely to vote for Ryan's bill.
What will quite likely happen is that the whole effort will fall apart in disarray. The Republican Congress could miserably fail its first major attempt at governing, to put it slightly differently. This should come as no real surprise, to anyone who has been paying attention for the past six years. The Tea Party has always been known for its skill in blowing things up, refusing to budge from the most extreme position imaginable, and viciously attacking fellow Republicans who weren't deemed sufficiently pure. It's kind of what they do, right? So why would anyone expect them to act any differently now? Time after time, the Tea Partiers have torpedoed conservative attempts to govern by arguing they were only getting 80 or 90 percent of what they wanted, instead of the whole cookie jar. We'll be in for another of these fights soon, as we approach a debt ceiling deadline later this year.
With the Tea Partiers being egged on by powerful conservative special interests, they're not likely to back down any time soon. So we'll be in for a whole lot of denunciations of fellow Republicans from them in the coming weeks. The problem, as always, is that the Tea Partiers have painted themselves into a pretty severe corner. These are the people who actually believe that Obamacare is so disastrous that it simply cannot have helped anyone, anywhere. They've firmly convinced themselves of this, and no evidence to the contrary will even be considered. This makes things very tough for Republicans who can actually see that Obamacare has had some very positive impacts, and who desperately want to keep as many of the good parts as they possibly can. It is arguing facts versus naked emotion, and for Tea Partiers, emotion always wins that battle.
There's a reason we haven't seen any GOP Obamacare replacement bill until yesterday. If some magic conservative plan had ever existed which was actually better than Obamacare -- either covered more people, or covered people cheaper, or had any other better outcome -- then we would have seen it by now. The simple fact is that such a plan does not exist and probably cannot exist. Obamacare certainly isn't perfect, but it has been pretty impressive in two of its main goals -- getting rid of the worst of the excesses of the insurance companies (like barring sick people from buying insurance, for instance), and getting millions more Americans insured. Any Republican plan is likely going to cover a lot fewer people, and force a whole lot more into paying more money than they do now. Now that Ryan's plan has been made public, these calculations can be made. Ryan is desperately trying to save the good parts of Obamacare and get rid of the insufficiently-conservative parts, but any effort to do so is almost guaranteed to raise prices or cover fewer people. Already, Republicans are lining up either on the side of the purists, who believe that all of Obamacare needs to be scrapped without any real replacement, or on the side of the realists, who know that when the numbers are crunched, their states are going to come out on the losing end of the stick.
The battle lines have been drawn. The crowd is being whipped into a frenzy. This intraparty Republican fight is going to get pretty vicious in the weeks to come, if previous Tea Party behavior is any guide. It's hard to imagine what tweaks Ryan could make to his bill to satisfy the purists. If Ryan's bill fails to pass, it's pretty hard to imagine any sort of compromise is possible within the GOP. Repeal and replace has been a dandy political slogan to use out on the campaign trail, but if Republicans prove unable to do so they will have failed their first big test on governing. If Paul Ryan can't get his caucus together on this, then we should all expect nothing more than total gridlock from the Republican Congress on a whole raft of other important issues as well. I'll even go out on a limb and predict that if Ryan fails to pass his Obamacare replacement bill, then he will likely step down from his speakership within the next year. Like Boehner before him, Ryan is fast learning the Tea Party is much better at blowing things up than they are at getting things done.
-- Chris Weigant
Follow Chris on Twitter: @ChrisWeigant