The health care industry killed Hillarycare in the 1990s and cut deals to shape Obamacare more to its liking in 2009. But now, as Republicans push a sweeping and widely reviled health bill through Congress, the industry has often appeared declawed in the biggest health care fight of the decade.
It's a deliberate strategy, interviews with nearly 20 lobbyists and other experts suggest. Health industry groups generally don't love Obamacare enough to jeopardize their ability to shape the rest of the Republican agenda — including big corporate tax cuts. They also fear incurring White House retaliation.
The Trump administration has already leveled direct threats to cut off federal subsidies to health insurers and to go after the drug industry, and Republicans hold the purse strings for the federal programs that cover many of the patients seen by the nation's doctors and hospitals.
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Further complicating matters, different sectors within the industry have very different stakes in repealing Obamacare and replacing it with the GOP's plan. Many health insurers are already ambivalent about Obamacare and could see significant tax cuts if the law is rolled back. Doctors and hospitals, on the other hand, could face a surge in uninsured patients if millions fewer Americans have health coverage.
As a result, those groups have not collectively gone all out, on the airwaves or in the halls of Congress, to stop the GOP's health care bill — even though they have expressed almost unanimous opposition to it.
"It's not all-out warfare," said Kim Monk, who tracks the health care debate in Washington for investors at Capital Alpha. "Republicans are going to be around for a while, and they tend to be your allies on really important things."
The House legislation is projected to lead to 23 million fewer Americans having health insurance in 2026 and include an $830 billion cut to Medicaid, the nation's largest insurer and a critical safety net for the most vulnerable Americans — and an important source of revenue for hospitals and doctors.
But other looming bills also mean big money for the industry. Republicans want to resolve health care so they can move on to a tax overhaul, expected to include a big corporate tax cut that many health care companies could benefit from. Repealing Obamacare's taxes on the industry, plus that corporate tax cut, could save health care companies upward of $200 billion over the next decade, by some rough estimates.
There are also more legislative items coming, including federal spending bills and reauthorizations of health programs, for which the industry wants a seat at the table.
"All these groups have things that they want," Monk said. "They're all similarly motivated in that it's not just about the [Affordable Care Act]. They know they have a few years ahead of issues they have to navigate."
So there are no "Harry and Louise" ads, the TV spots credited with sinking Bill Clinton's health care plan. "There is a significantly lower level of engagement of the sectors writ large across the board," one lobbyist, who like most others spoke on the condition of anonymity, said. This lobbyist has worked in Washington for more than 20 years and has seen several high-profile health care fights.
"I'm surprised we haven't seen some of these larger trade associations and patient groups band together," this lobbyist said. "Have a dialogue and a conversation about this, really point out the shortcomings of the House bill and whatever emerges from the Senate."