What happened in the Senate early Friday morning was a rarely seen political event of the sort last observed in September 2008, when a financial bailout vote unexpectedly failed on the House floor. Republican leadership thought they’d lined up the 50 votes necessary to pass a “skinny repeal” health care bill in the Senate. They had only 49.
Senate Majority Leader Mitch McConnell has had plenty of failures, along with plenty of successes. But it’s rare for Senate or House leadership to send votes to the floor unless they know the outcomes ahead of time and even more unusual for them to fail in such embarrassing fashion.
All of this drama obscures a more important point, however: Republicans have not yet come all that close to passing the health care bill they wanted. And they didn’t come that close Thursday night. True, the Senate was just one vote short of approving “skinny repeal.” But even if the Senate had approved the bill, they still had a long way to go in a process whose outcome was highly uncertain.
Many Republicans who voted for “skinny repeal” didn’t like it on its own terms — South Carolina Sen. Lindsey Graham called it a “disaster,” for instance — but instead viewed it as a vehicle to open up negotiations with the House on a more sweeping bill. But there’s no indication that a more comprehensive measure cooked up in those negotiations could have passed the Senate. Instead, McConnell had repeatedly failed to secure enough support for the Senate’s original health care bill, the Better Care Reconciliation Act; a vote to advance that bill failed 43-57 on Tuesday, with nine Republican defections.
If the House and Senate were unable to agree on a compromise, the House could have voted on “skinny repeal,” which — having already been approved by the Senate — would have gone to the president’s desk. The terms of the legislation, officially called the Health Care Freedom Act, included the provision to defund Planned Parenthood and other “goodies” that seemed designed to win over conservative votes in the House.
But “skinny repeal“ was massively less ambitious than the Senate’s BCRA or the House’s American Health Care Act. It wouldn’t have touched Medicaid. It wouldn’t have affected the Obamacare subsidies or the way the program was structured. And one of its key provisions, the repeal of the employer mandate, would have expired after 2024.
“Skinny repeal” would have eliminated the individual mandate, but even that wasn’t necessarily a conservative priority. Instead, the individual mandate had once been proposed by the conservative Heritage Foundation. (Conversely, Barack Obama’s health care plan did not include an individual mandate when he was a presidential candidate in 2008.) Instead, the individual mandate — or some other mechanism like it — was a necessary evil to prevent a potential death spiral on the health care exchanges. Without the individual mandate, the Congressional Budget Office estimated, premiums on the exchanges would have increased by 20 percent next year, and the number of uninsured people would have grown by 16 million. Republicans would probably have “owned” these problems if they’d enacted “skinny repeal,” while getting few of the things (such as major tax cuts) that they really wanted. Thus, there was a lack of enthusiasm for the bill among a wide range of conservative and more mainstream Republican figures, including people like Graham and Sean Hannity.
There was also a third possibility: that despite the Senate passing “skinny repeal” last night, Republicans would have been unable to finalize any sort of health care bill at all. Bills that reach a House-Senate conference usually become law in some form, but there have been exceptions, and most legislation is not as contentious as health care.
So rather than talking about the GOP’s near miss on Friday morning, it might be better to ask why they’ve had so much trouble passing a health care bill. The 30,000-foot answer, in my view, is simply that they overreached.
Health care reform was never going to be easy for Republicans. About two-thirds of Americans are happy with their current health care coverage, so they’re inherently nervous about changes to the system. But the GOP chose a course that was massively disruptive — under BCRA, 22 million people would have become uninsured within 10 years — in a way that was out of all proportion to the narrow mandate that President Trump and Republicans received last year.
It’s worth bearing in mind that Trump lost the popular vote and won the decisive state in the Electoral College, Wisconsin, by less than 1 percentage point. He’s also historically unpopular for this stage of his term, with a 38 percent or 39 percent approval rating. Meanwhile, Republicans lost seats in both the House and the Senate last year, and Republicans are in a significant deficit with Democrats in voter preferences for control of the next Congress. Special election results so far also suggest a potential backlash against Trump and Republicans, with Democrats having run well ahead of how they typically perform in those districts.
Nor were AHCA and BCRA the sorts of policies that Trump had promised to voters. Instead, Trump had pledged to protect Medicaid and to replace Obamacare with “something terrific” that provided more coverage at a cheaper price.
It’s not a surprise, therefore, that AHCA and BCRA were massively unpopular. The five most recent polls on BCRA had shown an average of just 24 percent of voters in favor of the measures but 53 percent opposed, the sort of lopsided numbers that are rare in this highly partisan era.
Exactly how responsive Republican members were to these popularity numbers — and to other signs of resistance, such as protests and phone calls — is hard to say. None of the three “no” votes — Susan Collins, Lisa Murkowski and John McCain — is all that electorally vulnerable (and McCain might not run for re-election again because of his health). But they aren’t the only members of Congress to have created resistance to passage at various stages of the health care debate; nine senators voted against BCRA earlier this week, for example, as I mentioned.
If McConnell and House Speaker Paul Ryan had started with “skinny repeal” rather than defaulted to it as a last resort, they might have had more of a chance. The individual mandate, which would have been eliminated under “skinny repeal,” is quite unpopular. But they poisoned the well by putting forth unpopular plans such as BCRA first, losing trust not only with the public but also with an increasing number of Republican members of Congress, some of whom had accused them of duplicity in the process so far.
McConnell and Ryan aren’t the only leaders who shot for the moon when their parties had congressional majorities. Democratic leaders Nancy Pelosi and Harry Reid also did this in 2009 in seeking to pass Obamacare. But Pelosi and Reid had much larger majorities in 2009 than Republicans do now, and a much more popular president in Obama. Even then, Democrats still paid a significant electoral price for their health care bill, with a disastrous midterm in 2010. McConnell, Ryan and Trump will pay a political price too, one way or another — and now it looks like they won’t get a health care bill to make up for it.