Back in 2014, seven Democratic senators introduced a bill to modify the Affordable Care Act by allowing state-run exchanges to feature high-deductible, low-premium "copper" plans that they thought would be attractive to uninsured people whose incomes were too high to let them qualify for much if anything in the way of ACA subsidies. It wasn't a panacea by any means, but it probably would have helped some people, and it would have done so in a way that accorded with the conservative criticism that the ACA was overly prescriptive about how generous insurance needed to be — pushing premiums unnecessarily high and forcing unsubsidized customers out of the market.
Two of those seven senators lost their seats in the 2014 midterms but the other five are still all in the Senate today. And to the best of anyone's knowledge, none of them were brought into the White House for any meetings with the president or anyone on his staff during the current health care debate.
That, despite Trump's whining about having been "let down by all of the Democrats," is the simple explanation for why Trump was unable to obtain any measure of bipartisan support for his health care initiative. He never tried.
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Republicans never tried to write a bipartisan bill
And of course it wasn't just Trump. Nobody in Senate Republican leadership met with the Copper Five — Mark Warner, Heidi Heitkamp, Tim Kaine, Angus King, and Joe Manchin — either. Nor were other electorally vulnerable Democrats like Joe Donnelly or Claire McCaskill — who must have been fairly desperate to find an issue or two on which they could say they were working with the Trump administration — invited to participate in any way.
If the White House decides they want to keep their promises — preserve Medicaid, expand coverage, and improve the quality of plans available — the only way to do that is through a bipartisan deal.
When Mitch McConnell formed his working group on health care legislation, it was — despite his pious complaint on the House floor that Democrats "did not want to engage with us seriously" — a one-party affair. And he seems to have mostly ignored even that group in favor of a tightly held, leadership-driven process. Trump, meanwhile, has shown zero interest in any of the specific aspects of health care legislation. But despite this, he's also shown zero interest in bipartisan dealmaking — simply outsourcing all the work to McConnell and Paul Ryan, who've proceeded in a hyperpartisan manner that fits their role as party caucus leaders rather than broad stakeholders of the national interest.
And yet the Trump administration, absurdly, has decided to cast Democrats as the reason the GOP can't make the math work on a repeal bill.
A GOP divided against itself
Legislating is fundamentally difficult. The United States has only two big political parties but a wide range of views on important issues. Building consensus inside even one party is inherently hard.
But for all that Democrats disagree among themselves about important aspects of health care policy, they were able to make the Affordable Care Act work due to very broad consensus inside the party that getting more Americans enrolled in comprehensive health insurance was a good idea. That consensus made them willing to raise taxes and cut Medicare Advantage spending to obtain the funds needed. It made more left-wing members willing to drop dreams of a big new public program and more centrist members willing to drop hostility to expansion of Medicaid. It made everyone willing to vote for an individual mandate that they knew was unpopular but believed to be technically important.
Republicans, by contrast, are fundamentally stuck between two commitments:
- They promised to repeal Obamacare, a law that polls very poorly with their base and which their major donors hate.
- They also promised to keep the popular parts of Obamacare, like protections for people with preexisting conditions and gains in the number of people with insurance coverage.
On the campaign trail, Republican politicians smoothed out the differences with a lot of whining and hand-waving. Everyone from Trump to McConnell and beyond promised a nonspecific replacement that would scrap taxes and mandates while somehow (magically?) offering more and better coverage.
To govern is to choose
In governing mode, this doesn't work. Party leaders had to pick what they wanted to do.
They decided they wanted to write a one-party bill, which meant they needed a bill that right-wing ideologues from safe seats could get behind. In practice, that's meant gutting regulatory protections for patients and proposing cuts in Medicaid that go well beyond reversing the ACA's Medicaid expansion.
These are ideas that are so profoundly unpopular even Republicans campaigned against them to win elections. And because the ideas are unpopular, even red-state Democrats have felt no compunction to pull punches in their opposition.
Donald Trump won 68 percent of the vote in West Virginia, but then managed to throw his weight behind health care legislation that would be so devastating to the state's economy that it turned into an easy "no" vote for Joe Manchin and a tough vote for Shelley Moore Capito, who helped kill a repeal-only bill this week.
That's a tough blow, but it's also an inevitable result of the choice to resolve the contradictions of GOP health care promises by siding with the far right of the party rather than searching for a bipartisan deal.
The art of the deal
If the White House decides they want to keep their promises — preserve Medicaid, expand coverage, and improve the quality of plans available — the only way to do that is through a bipartisan deal. A group of moderate House Democrats recently released a menu of mostly very modest, mostly very cheap tweaks that would help make exchanges work a lot better.
One could imagine pairing those with the moderate Senate Democrats' copper plan idea and say that you were both making technical fixes to the ACA and shifting its vision of health care closer to the direction of conservative wonks.
Arkansas's so-called "private option" for Medicaid, in which state waivers were used to transition much of the Medicaid population onto the state exchange for purchasing private insurance, is another promising model of a good-faith bipartisan compromise on a contentious issue.
Last but by no means least, the two different repeal bills have revealed something important about the dreaded individual mandate. This is an idea that Congress and the public have always hated — it's so unpopular that Barack Obama campaigned against it in the 2008 primary — but that a certain segment of experts talked themselves into deeming necessary to make the individual market work. In practice, the mandate's unpopularity led to it being enacted in a fairly weak form that doesn't accomplish an enormous amount. And both the House's AHCA and the Senate's BCRA featured alternative regulatory moves to incentive the voluntary purchase of insurance that the Congressional Budget Office thinks will work about as well.
Democrats have long complained that the GOP promise of keeping the popular parts of the ACA while ditching the unpopular mandate is impossible. Republicans have, in fact, shown that's not really true. It's just that they then paired their solution with a bunch of other unpopular ideas. But separating out the GOP solution, pairing it with some Democratic ideas to improve the ACA, and maybe fiddling around with the taxes some could generate a bipartisan bill that actually fulfills the promise to replace Obamacare with something better. But to get it, Trump would have to tell Paul Ryan, the Freedom Caucus, and the GOP donor class to take a hike.
Commentary by Matt Yglesias, a writer at Vox. Follow him on Twitter at @mattyglesias.
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