Repeal, Replace & Repeat

What Republicans’ failure on health care shows us about the current landscape and the near future of Obamacare

Illustrator: Katie Heywood

Conventional wisdom, or what remains of it, asserts that a politician’s main priority is to get re-elected. Often, they accomplish this by passing popular legislation, less often by passing good legislation. So why have Republicans in Congress continued to push a health care bill that is not only incredibly unproductive, but even more unpopular?

Since last January, Senate Republicans have tried, and failed, to repeal and replace Obamacare four times—the last being the Graham-Cassidy plan.

Whether it was the “skinny repeal” or the original BCRA, every attempt thus far has been a complete and total mess.

Republican plans would roll back Medicaid, reduce public insurance subsidies, increase out-of-pocket costs, and weaken protections for people with pre-existing conditions. For earlier versions, the CBO projected around 20 million more people to be uninsured over the next decade; a preliminary estimate of the Graham-Cassidy plan indicated “millions more” without health insurance. In most ways, Republicans’ plans would eliminate the most popular portions of Obamacare, while keeping the rest.

Perhaps that’s why a dismal 20 percent of the public supported Republican health care bills.

After campaigning on this promise for the past six years, Republicans somehow concocted the worst possible solution to repeal Obamacare—harmful to both the public and the party. Their plans were so bad they actually raised the popularity of Obamacare; for the first time, a majority of Americans now support the ACA.

One would think Republicans would learn their lesson, if not after their first failure, then after their last. Yet, Republicans remain steadfast in their objective to completely destroy Obamacare.

After the failure of his own plan, Sen. Lindsey Graham, R-S.C., said, “Today to me, it’s not a matter of it, it’s now when … I see enthusiasm for the first time among Republicans about an alternative to Obamacare.”

Sen. Mike Crapo, R-Idaho, explained, “There’s also a very strong attitude that we’re not going to stop trying. We can’t. We just have to keep working at it.”

Despite clear opposition from the public and potential political repercussions, Republicans will likely try again on repeal and replace next year. Which makes many wonder: Why are they so hell-bent to pass healthcare legislation? And if they are so determined, why can’t they?

Path Dependency: The Trouble of Going Back

The answer may lie in a political process known as “path dependency.”

Path dependency holds that previous outcomes influence, shape, and limit options currently available. Or as economist David A. Paul put it, “One damn things follows another.”

Once a decision has been implemented, it becomes difficult to reverse it. A specific path forward emerges; diverting from it presents significant challenges.

In this way, certain policies become entrenched in a country’s political system—long-lasting programs like Social Security and Medicare remain influential pieces of legislation, untouched by time.

As described by The New York Times, “Modern American history makes it clear that once the social safety net expands in a major way, it’s almost impossible for anyone to reverse it.”

The passage of Obamacare significantly influenced the system of health care in the U.S. Like Medicare, Obamacare rapidly became entrenched in the American political landscape.

Its creators strategically designed the ACA to take hold quickly. Obamacare’s more appealing elements—including protections for pre-existing conditions, staying on parents’ programs until 26, and expanding Medicaid—were implemented first. Less popular provisions, like the individual mandate and increasing yearly fines, took place later. Obamacare handed out candy in the short term, prescribing the medicine later on.

Unfortunately for its critics, the longer Obamacare remained intact, the more difficult it became to dismantle. And Republicans knew it.

Obamacare handed out candy in the short term, prescribing the medicine later on.

Since day one, Republicans furiously attacked the ACA with everything they had. They critiqued the policy using outright misinformation, projecting fear about so-called “death panels.” Rep. John Fleming, R-La., called the ACA “the most dangerous piece of legislation ever passed … as destructive to personal and individual liberties as the Fugitive Slave Act.”

The GOP won back the House in 2010 and the Senate in 2012 campaigning on the repeal of Obamacare. They have attempted it 50 times since its passage. After President Trump’s inauguration, it was one of the first items on their agenda. They understood time was of importance.

But Republicans were too late. By the time they had the voting power, the ACA was fully implemented across the country. With nearly two terms of protection by way of President Obama’s veto, in addition to multiple Supreme Court decisions reaffirming major provisions, the ACA is likely here to stay.

Former Republican Speaker John Boehner recently recognized that. Boehner—who fully opposed the ACA while in office—publicly said a repeal and replace of Obamacare is “not what’s going to happen.”

Once you provide Americans with health care, it becomes difficult to take it away.

But why have Republicans kept pushing for repeal, knowing full well the obstacles?

The Future Obamacare Created

Many Republican legislators and strategists claim they are determined to stay true to their word and deliver on their campaign promises. Failing to do so, they say, would upset the conservative base.

But it’s hard to imagine stripping millions of people of their insurance puts Republicans in a better position heading into 2018 than not. If public opinion is any indication, passing repeal and replace probably is far more politically harmful for the GOP.

Again, path dependency might provide a more compelling answer: The options currently available are significantly influenced by past outcomes. As described by political scientist William Sewell, path dependency indicates, “What happened at an earlier point in time will affect the possible outcomes of a sequence of events occurring at a later point in time.”

Obamacare not only changed the current political landscape; it also completely transformed the future of healthcare in America. Beyond the ACA’s specific provisions and policy, Obamacare changed the course of what’s possible in coming years.

That future terrifies many members of the GOP.

Sen. Orrin Hatch, R-Utah, warned if a repeal doesn’t happen, “we’ll be on a fast track toward socialized medicine.” Other Republicans have shared his fear, claiming Obamacare began the trek toward federally-run health care.

And for once in the health care discussion, they might just be right. In many ways, Obamacare serves as the perfect foundation for a goal long sought by liberals: universal health care.

Obamacare was the first major health care reform in over 60 years. It expanded health care to over 20 million more Americans, in addition to increasing federal funding and support for insurance. A more ambitious form of the ACA even included a federally-run insurance program called “the public option”; it was eliminated in the final negotiations of the bill.

Political scientist Paul Pierce explains that for any major policy “preceding steps in a particular direction induce further movement in the same direction.” Obamacare was a first step toward expanding health care. It’s likely to continue.

What’s Now Possible

For Democrats, there is no time like the present to fight for the future of health care. The fact remains that nearly 30 million Americans are still uninsured, with even more people underinsured and/or struggling to pay for rising costs.

There’s the need for universal health care. And the political support. According to the Pew Research Center, 60 percent of Americans say the government should be responsible for ensuring health care coverage for all Americans. A recent Gallup poll found 58 percent of Americans believe in federally funded universal.

Already a majority of Democrats in the House support a single payer system; one third of Democratic senators came out in support of Sen. Bernie Sanders’, I-Vt., Medicare-For-All plan.

Heading in 2018, congressional Democrats have unleashed their “Better Deal” plan, which features better jobs, better wages, and a better future. Why not include better health care?

Obamacare has withstood Republicans’ fierce attacks, calculated plans, and determined resolve to repeal it. It has become a solid part of the American political landscape. More importantly, Obamacare transformed it.

What’s possible in the next decade—a universal health care system—comes from what Obamacare changed this decade. Now, it’s up to Democrats to embrace path dependency and push for health care Republicans cannot ever take away.