For obvious reasons, the big story out of the failed Republican effort to repeal Obamacare was the surprise tie-breaking vote cast by Senator John McCain. For political drama, it’s hard to beat a cancer-stricken war hero defying his party to save the health reforms engineered by the Democrat who denied his presidential dreams. But the “no” votes cast by Republicans Susan Collins and Lisa Murkowski were just as important as McCain’s, and so was the unified opposition of all 48 Senate Democrats. One could argue there should be even more attention paid to the grass-roots resistance that helped make repeal so toxic, and to the damage President Donald Trump’s passive-aggressive approach did to his own cause. Of course, the defeat of legislation that could have taken health insurance away from millions of Americans and protections away from millions more is also a big deal in its own right.
But the most remarkable takeaway from the defeat of repeal ought to be how close it came to passing.
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Forty-nine Republican senators voted for legislation that many of them admitted was substantively flawed and procedurally absurd—legislation that only 17 percent of the public supported and every major medical interest group opposed; that had been shredded by a bipartisan coalition of governors, the Congressional Budget Office and their own hand-picked parliamentarian. After Trump promised to expand coverage, lower costs and block any cuts to Medicaid, he almost got to sign a bill that the CBO warned would do exactly the opposite, leading to a massive expansion of the uninsured, higher premiums and deductibles for the old and the sick, and hundreds of billions of dollars’ worth of Medicaid cuts. After attacking Democrats for ramming Obamacare into law with only 60 votes after insufficient hearings, insufficient bipartisan outreach, and insufficient transparency, Republican senators nearly passed Trumpcare with only 50 votes after no hearings, no bipartisan outreach, and so little transparency that even most of them had no idea what would be in it until a few hours before their middle-of-the-night roll call.
This was a political train wreck, but if one Democratic senator had failed to show up for work last night, the wreckage could have been dragged into law. Even though Trump’s main message over the past week of debate was that his attorney general is a failure. Even though his new communication director’s main message on the last day of debate was that Trump’s (now former) chief of staff was a leaker. Even though polls suggested a vote for repeal could be electoral suicide for swing state Republicans like Senator Dean Heller. Even though health wonks warned that the bill could be particularly devastating for downscale older voters who make up Trump’s base. Even though the main groups representing seniors, doctors, insurers, nurses, hospitals and patients all warned that the bill could ravage American health care.
The last-minute survival of Obamacare is already deflating Majority Leader Mitch McConnell’s reputation as a Machiavellian legislative genius, but really, its near-demise ought to confirm his reputation for manipulative brilliance. Earlier this week, he persuaded 50 Republicans, including McCain, to vote to accelerate the repeal process, even though many of them, especially McCain, were trashing that very process as an irresponsible embarrassment to the Senate. He managed to keep almost all of his caucus together until the end, somehow convincing conservatives who thought the legislation was too timid and moderates who thought it was way too radical that he could magically square that circle. For all the mockery of Trump’s earlier tweet about how getting even 48 Republicans to back repeal was “impressive by any standard,” it wasn’t entirely wrong, especially considering the dysfunction of the White House and the unpopularity of the bill.
In fact, McConnell managed to get 49 Republicans on the bare-bones “skinny repeal” he pulled out of his hat late Thursday night, including Senator Lindsey Graham, who called the bill “a disaster,” and Senator Mike Rounds, who said it would create “a total collapse of the market.” It was never clear how any legislation that merged the skinny repeal with the more conservative bill the House passed could satisfy Senator Bill Cassidy’s “Jimmy Kimmel test,” guaranteeing unlimited medical care for any sick child, but Cassidy was a yes as well. So were Heller and Senator Shelley Moore Capito, who came out against taking away anyone’s Medicaid—Capito declared just last week that she “didn’t come to Washington to hurt people”—along with conservatives like Rand Paul and Ted Cruz, who wanted much bigger Medicaid cuts.
Ultimately, McConnell fell one vote short of papering over all those differences. He lost, so his completely partisan, intensely secretive, consistently deceptive approach seems outrageously cynical rather than brilliantly cynical. His decision to hold no hearings on Trumpcare after attacking Democrats for holding only 79 hearings on Obamacare seems like an appalling violation of Senate norms rather than a brilliant violation of Senate norms. Unsuccessful legislative efforts, like losing political campaigns, always seem dysfunctional in retrospect. But coming this close to passing this unpopular a bill was arguably the most dynamic feat of legislative leadership since, well, since McConnell violated Senate norms by keeping Merrick Garland off the Supreme Court.
Morally, McConnell didn’t cover himself with any glory by concealing what he was doing from the public and dissembling about its impact. But politically, it’s hard to see how openness and honesty would have promoted repeal. It’s never easy to take away an entitlement, and the “failing Obamacare” that Republicans have railed against for years bears little resemblance to the actual Obamacare. They voted for repeal bills all the time when they knew Obama would veto them, but once their bills had a possibility of becoming law, they faced real substantive problems that McConnell did the best he could to conceal.
The first substantive problem Republicans faced was that Obamacare, while imperfect, does many popular things that Americans don’t want undone. It extended coverage to 20 million uninsured Americans. It also included powerful guarantees to make sure the coverage is there when insured Americans need it, like a ban on insurers discriminating on the basis of pre-existing conditions, an end to caps on payments to patients who need a lot of care, and a requirement that all plans reimburse certain “essential benefits.”
The second substantive problem Republicans faced with repeal was that where Obamacare has encountered problems—primarily on the exchanges that cover about 3 percent of Americans who aren’t insured through the government or their employers—the GOP replacement plans would have made the problems worse. That’s because the GOP plans would get rid of Obamacare’s mandate to buy insurance, which would encourage more young and healthy consumers to drop their coverage, which would encourage more insurers to jack up premiums to deal with sicker populations or even abandon the exchanges altogether. And while most consumers on the exchanges are currently insulated from rising premiums because of Obamacare’s generous subsidies, the Republican replacement plans would roll back those subsidies.
This is why the CBO analyses of the various Republican options have been so brutal. This is why Democrats in Trump-friendly states like West Virginia and North Dakota have been just as consistent in their opposition to repeal as Democrats from California and Massachusetts. And this is why McConnell and House Speaker Paul Ryan had to figure out a way to satisfy moderates who wanted to preserve Obamacare’s coverage expansions and insurance protections as well as conservatives who insisted that the point of repeal was to get rid of them.
The final House bill basically steamrolled the moderates, but McConnell couldn’t afford to lose more than two of them in the Senate. His basic strategy was to avoid hearings that would expose all these contradictions, avoid committing to any particular vision of repeal for as long as possible, keep assuring his members that moving the process forward would eventually produce a better bill that would address their various concerns, and keep kicking the can down the road with the hope that the momentum for repeal would get too intense to resist.
That strategy might have worked even better with a popular president making a compelling case for change. But Trump was below 40 percent in the polls, and his health care messaging was a disaster. He wanted to win, and he clearly relished the idea of dismantling Obama’s signature achievement, but he never displayed much concern about or understanding of the health care system. He certainly never explained how any of the repeal bills would expand access or lower premiums or improve care, and his attention at key moments often drifted to his grievances about the Russia investigation. Whenever the politics in Congress took a negative turn, he vowed to let Obamacare implode, an attitude that did not suggest much empathy for the well-being of constituents on Obamacare. He repeatedly tried to bully uncooperative Republicans with ham-handed threats, and publicly complained that they should be loyal to him because he carried them into office. Perhaps his most self-defeating move was criticizing the House bill as “mean” after pressuring vulnerable Republicans to support it, serving notice to potential allies that if they climbed out on a limb for him he would readily saw it off.
Nevertheless, Republicans almost pulled off repeal. They could still try to stash elements of repeal in their 2018 budget. Trump seems determined to try to sabotage Obamacare, hoping that will bring Democrats around to repeal. And if McConnell brings up a bill again when one of the dissenters isn’t around to vote no, Republicans could still pull off repeal. McCain was just diagnosed with brain cancer, and Senator Mazie Hirono, a Hawaii Democrat, has kidney cancer. It would presumably violate Senate norms to take advantage of an illness, but McConnell doesn’t seem to lose much sleep over violating norms.
Ultimately, the broad support from congressional Republicans for ideologically extreme and wildly unpopular legislation that would have redistributed about a trillion dollars from health care for the poor and the middle class to tax cuts for the rich says quite a lot about today’s GOP. It is not a genuinely populist party, even in the age of Trump, and it can be incredibly brazen about ignoring facts that don’t suit its narrative. But it’s hard to see how the narrow defeat of legislation that hardly anyone really liked suggests that McConnell has lost his touch. Democrats have never underestimated him, and they would be dumb to start now. And with his agenda in peril while scandals swirl, Trump would be even dumber to pick a fight with the modern master of the Senate.