Why Trump's Efforts To Repeal And Replace Obamacare Will Fail: Part I-Partisan Opposition. {Part II will be posted separately.VM}

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JAN 31, 2017 @ 09:46 PM

Why Trump's Efforts To Repeal And Replace Obamacare Will Fail: Part I-Partisan Opposition.

The Apothecary

Insights into health care and entitlement reform. 

Opinions expressed by Forbes Contributors are their own.

Chris Conover, Contributor

My doctorate in public policy is from the Pardee RAND Graduate School. Some readers will know the RAND Corporation was long the home of Herman Kahn, a futurist who was infamous for writing a book Thinking the Unthinkable, which assessed how the United States could survive and win a thermonuclear war.

A thermonuclear war surely would pose a barrier to President Trump's plans to repeal and replace Obamcare. But that's not what this three-part series of posts is about. In the spirit of futurist thinking, I'd like to ponder some of the most serious roadblocks that stand in the way of President Trump attaining his stated policy objective. Today I will start with partisan opposition since if repeal and replace efforts ultimately fail, history books are likely to accord high importance to this factor. Part II is here.

Overview

The biggest roadblock, of course, is opposition by Democrats in Congress.

? Within weeks of the election, well-known progressive pundit Ezra Klein argued that in light of their popular vote majorities in both presidential and Senatorial races, “Democrats need to be an opposition party, not a minority party.”

? In early January, President Obama met with Democrats in Congress to argue for steadfast opposition to any efforts to repeal the ACA.

? The very next day, Senate Minority Leader Chuck Schumer held a press conference, at which he stood next to a whiteboard with the words “MAKE AMERICA SICK AGAIN” on it.

? Just today, Democrats on the Senate Finance Committee boycotted planned votes on the nomination of fierce Obamacare critic Tom Price to become Secretary of Health and Human Services. In light of concerns over ethics violations [1], it remains to be seen whether Dr. Price will survive the confirmation process [see Update #2 below]. If for whatever reason he does not, this would be a serious blow to efforts to repeal-and-replace Obamacare as Dr. Price's experience in Congress and deep knowledge of the issue make him uniquely qualified to quarterback this very challenging effort.

iven all the hand-wringing over Republican "obstructionism" during former president Obama's 8 years in office, such intransigence might appear hypocritical.

Lack of Mandate

But Democrats are quick to point out that President Trump lacks a mandate to make any bold policy moves:

? Popular Vote Margin. Leaving aside his losing by nearly 2.9 million votes, Mr. Trump's popular vote deficit (2.1%) gives him the third-worst vote margin among winning candidates in American history.

? Electoral Vote Percentage. The president won 30 states, gathering 304 of 538 (56.5%) electoral votes (2 electors designated for Trump opted not to vote for him). However, there have been 45 presidential elections in which the winning candidate won a larger share of the electoral vote.

? Vote Share Needed to Reverse Election. A swing of just under 40,000 votes in 3 states (MI, PA, WI) would have given the election to Democrats; this represents 0.0293% of votes cast, making it the 7th closest presidential election in history in terms of this metric (p. 330).

? Public Opinion. Reflecting Mr. Trump’s loss in the popular vote, only 29 percent of Americans say that Mr. Trump has a mandate for the agenda he offered during his campaign, according to a Washington Post-Schar School of Policy and Government poll.

8 Senate Votes Needed for Replacement Plan

With the recent Senate and House passage of a budget resolution containing instructions for repeal, Republicans have kicked off the process of repealing a large part of the law through budget reconciliation. This is something they can do on a strict party-line vote, if need be. But to repeal the insurance rules that have caused premiums to sky-rocket (e.g., the individual mandate, restrictions on age rating, the requirement to cover pre-existing conditions etc.), Republicans will need the votes of 8 Democrats to overcome a filibuster.

Republicans could, in theory, get rid of the filibuster, but Senate Majority Leader Mitch McConnell (R., Ky.) and others have routinely expressed opposition to that idea.

Democrats have to contest 24 seats in 2018, versus only 8 for Republicans, so prospects favor Republicans to deepen their margin midway through Trump’s first term. This certainly could give Senator McConnell important leverage in securing the votes he needs:

? 10 Democrats facing 2018 re-election are from states won by Trump: Nelson (FL), Donnelly (IN), Stabenow (MI), McCaskill (MO), Heitkamp (ND), Tester (MT), Brown (OH), Casey (PA), Manchin (WV) and Baldwin (WI).

? Six of these 10 are in states that Trump carried by substantial margins. Five of these six states also went for Mitt Romney in 2012.

It is worth remembering that almost 3 years ago, six Democrats in the senate introduced a bill to make changes in Obamacare when it was under extreme fire due to a very rocky rollout. These included Mary Landrieu (LA) and Mark Begich (AK)--both defeated in 2014--along with . Heitkamp (ND), Angus King (I-ME, who caucuses with Democrats), Manchin (WV) and Warner (VA), who was re-elected in 2014. 

More recently, Sens. Claire McCaskill (D-MO) and Angus King both have expressed interest in a bipartisan replacement plan, but only if it makes modest changes to the law.

Moreover, according to The Hill, "Senate Democratic Leader Chuck Schumer (D-N.Y.) has made it crystal clear: If Republicans repeal ObamaCare without immediately implementing a plan to replace it, Democrats will not help them out of a pickle down the road. Senate Democratic sources familiar with Schumer’s thinking say he will not engage in any negotiations to pass a watered-down version of the landmark healthcare reform law if Republicans unilaterally force its repeal first under special budgetary rules."

In the aftermath of this hardline position, Sen. Ron Wyden (D-OR)--deemed "the last bipartisan" by Bill Keller at the New York Times--has said he would not participate in the Republican effort to overhaul the nation’s healthcare sector as it’s now planned. 

Replacement Plans That Would Expand Coverage Relative to Obamacare

While this picture looks bleak, Senator Schumer also has suggested Democrats would work with Republicans to improve Obamacare or even pass a comprehensive reform bill replacing it under certain conditions: “So long as it covers as many people as the ACA, so long as it helps bring healthcare costs down, so long as it doesn’t move our healthcare system backward.”

I've earlier alerted readers to three Obamacare replacement plans that would cover more people than Obamacare: a) Avik Roy's Transcending Obamacare plan would cover 12 million more uninsured; b) AEI's Improving Health And Health Care Plan would cover 16 million more uninsured; and c) AEI's Best of Both Worlds plan would cover 19 million more uninsured.

In principal, any of these plans might command bipartisan support: indeed, each was designed with that purpose. But the way these plans expand coverage while also saving money is by substantial reform of Medicare, Medicaid or both, including such measures as Medicare premium support, increases in the eligibility age for Medicare and Medicaid block grants. However, such reforms have been fiercely resisted by Democrats in the past.

Who Will Get Blamed for an Impasse? 

According to The Hill, "Schumer’s view and the prevailing view in the Democratic Caucus is that they should not lift a finger to help Republicans out of a political mess if they repeal the healthcare reform law without having a replacement ready to avert severe market disruptions.

“If they want to rip healthcare away from 22 million Americans, they don’t get to blame us for not cobbling something back together,” the lawmaker said."

Republicans Previously Blamed for Government Shutdown. It is certainly true that the public blamed Republicans, not Democrats, when Senator Cruz managed to get the government shut down for 16 days in his failed effort to defund Obamacare. According to a Washington Post/ABC News poll conducted several months following the shutdown, 81% of Americans disapproved of the shutdown, 86% felt it had damaged the United States’ image in the world, and 53% held Republicans accountable for the shutdown. 

The High Electoral Price of Obamacare. That said, at the ballot box, Obamacare has been disastrous for Democrats.

? 2016 Presidential Election. It's not a slam dunk, but it is reasonable to conclude that dissatisfaction with Obamacare was a deciding factor in Hillary Clinton's loss in 2016.

? 2014 Senate Elections. The disastrous rollout of Obamacare in fall 2013 was "Obama's Katrina" according to the New Republic. Every new GOP senator who won in 2014 campaigned on repealing Obamacare.

? 2010 House Elections. Republicans gained 63 seats in the House in 2010, taking the majority away from Democrats. A careful political science study found that at least 25 members of Congress lost their seats in Congress during the 2010 elections because they voted for ObamaCare. It concludes by simulating counterfactuals that suggest health care reform may have cost Democrats their House majority.

? Governors. Democrats have 10 fewer governorships in 2016 than they did in 2008, reducing their total number of state executives from 28 to 18.

? Clearly not all of these losses can be attributed to Obamacare. However, in a Politico story published in February of 2015, Democratic governors attributed the losses experienced in 2014 specifically to a few factors, including "bad luck, bad timing and an unpopular president."

? Obama has mostly had approval ratings below 50 percent, which surely must be related in part due to Obamacare's never having commanded majority support in the RealClearPolitics poll average since the law was enacted. For that matter, RCP poll averages also show that the share of the public favoring repeal has been at least 5 percentage points higher than the fraction who oppose it.

? State Legislatures. At the beginning of Obama’s term, Democrats controlled 59 percent of state legislatures, while in January 2017 they controlled only 31 percent, the lowest percentage for the party since the turn of the 20th century. They held 29 governor’s offices and by January 2017 had only 16, the party’s lowest number since 1920.

? State Trifectas. A state trifecta control is when one political party holds majorities in both chambers of a state legislator and the governorship.

? According to the National Conference of State Legislatures, in early 2009 Democrats had 17 state trifectas while Republicans had nine.

? However, by 2016 the number of state trifectas the Democrats held was reduced to six: California, Delaware, Hawaii, Oregon, Rhode Island, and Washington State. Republicans now have 24, plus Nebraska's unicameral legislature and governorship,

Sean Trende and David Byler have calculated that the Republican Party is now in the strongest position it has been in 80 years. 

Bottom Line

In short, Obamacare has turned into an enormous political gift to Republicans over the past 8 years. In principle, recognition of this fact might induce Democrats to cooperate with Republicans in finding a way to sensibly replace this misguided law. After all, continuing on their losing electoral trajectory will greatly diminish their prospects for ever returning to the partisan dominance they had in Washington or statehouses at the beginning of former president Obama's first term.

Conversely, however, bitterness over this same set of facts might induce Democrats to dig in hoping for an enormous reversal of fortune. The popularity of Donald Trump likely will play a crucial role in their perceptions of how they play their hand.

Readers can decide for themselves how this hugely consequential pitched battle is going to play out. But in the next post, I will suggest some other reasons the repeal-and-replace effort could fail even in the face of bipartisan support.

Update #1: February 1, 2017

I have added a footnote with further details over ethics concerns as reported last night in Washington Post.

Update #2: February 1, 2017

The Senate Finance Committee has approved Tom Price's nomination for Health and Human Services secretary after suspending the rules to be able to vote with no Democrats present. Senate Finance Committee chairman Orrin Hatch told reporters that "the parliamentarian told us this is what we have to do," and said all committee members were notified in advance. As I noted in my piece, this is very good news for repeal-and-replace efforts, though it obviously does not guarantee success.

In the meantime, however, today's Wall Street Journal reports " President Donald Trump’s aggressive White House debut is stoking a war with Democrats and creating unease with fellow Republicans, dimming chances for cross-party compromise and potentially limiting the scope of what he can get done while in office." Needless to say, this is not good news for the push for repeal-and-replace.