Republican governors played a leading, perhaps decisive, role in the collapse of their party’s long-promised legislation to repeal the Affordable Care Act, known as Obamacare.
With Ohio Gov. John Kasich and Nevada Gov. Brian Sandoval leading the way, GOP governors prodded senators from their home states to reject the Better Care Reconciliation Act, which would have replaced Obamacare with a measure that reduced the funding and changed the structure of Medicaid, the federal-state program that provides health coverage for low-income Americans and the disabled.
The BCRA, the fourth version of a Republican replacement, was put forward by Senate Majority Leader Mitch McConnell, R-Ky., and backed by President Donald Trump.
McConnell conceded the bill was dead after Republican Sens. Mike Lee of Utah and Jerry Moran of Kansas joined Sens. Susan Collins of Maine and Rand Paul of Kentucky in opposition. Collins said eight to 10 other senators had reservations.
One of the Republican senators on the fence is Dean Heller of Nevada, a likely target of Democrats when he seeks re-election in 2018. He sought guidance from Sandoval, the first Republican governor to expand Medicaid under the Affordable Care Act.
More than 200,000 Nevadans receive Medicaid coverage because of this decision. Pressed by Vice President Mike Pence to support the BCRA, Sandoval insisted the Trump administration numbers on Medicaid did not add up. As one official put it at the National Governors Association conference: “You can’t repeal math.”
Republicans are walking a tightrope as they try to redeem — or dodge — their promises of the last seven years to repeal Obamacare, and Heller has less room to maneuver than other GOP senators.
He’s indebted to Sandoval, who appointed him to the Senate in 2011 and helped him narrowly win election in 2012. When Heller echoed Sandoval and expressed doubts about the BCRA, a pro-Trump group launched a $1 million television campaign in Nevada that savaged Heller for reneging on his promise to help repeal Obamacare.
Sen. Rob Portman, R-Ohio, has more running room, for he was re-elected last year after a campaign that kept its distance from Trump. Nonetheless, he’s often on the same wavelength as Kasich, who also expanded Medicaid under the ACA. More than 700,000 Ohioans signed up. Portman joined Kasich in criticizing the magnitude of the proposed Medicaid reductions.
The path to passage was always uphill for McConnell. Because all 48 Democratic senators opposed the bill, McConnell needed the votes from 50 of the 52 Republican senators to reach a 50-50 tie that Pence would break.
Instead, Republican senators wavered in the wake of an NGA conference at which governors of both parties questioned the proposed Medicaid changes. In addition to Sandoval and Kasich, Republican governors of Arkansas, Maryland, Massachusetts and Vermont joined in the criticisms.
For states, and the more than 70 million people who benefit from its services, Medicaid is a crucial component of health care. Jointly funded by the federal government and the states, Medicaid cost $574 billion in fiscal 2016 and accounted for 21.5 percent of expenditures from state general funds. It is the biggest item in most state budgets after K-12 education.
Unlike the federal government, states are required to balance their budgets and have struggled with Medicaid costs since the Great Recession of December 2007-June 2009.
When the then-Democratic-controlled Congress passed the Affordable Care Act in 2009, it gave states a break by having the federal government pay 90 percent of the costs of new recipients. With this incentive, 31 states and the District of Columbia expanded Medicaid.
These subsidies would have been phased out under the BCRA. Even more alarming to the governors, the Senate bill would have replaced the current open-ended Medicaid with block grants. As governors of both parties observed, this was likely to squeeze the states in economic downturns, when Medicaid usage increases and revenues decline.
It is easier to oppose than to enact. After Republicans won control of Congress in 2010, the House of Representatives passed more than 50 bills repealing Obamacare. Most of them died in the Senate. The lone bill that cleared both houses was vetoed by President Barack Obama.
Trump promised repeatedly during the 2016 campaign to repeal the Affordable Care Act and replace it with something “wonderful” that would benefit everyone.
“Real change begins with immediately repealing and replacing the disaster known as Obamacare,” he said.
When Trump won while Republicans retained control of Congress, the ACA seemed doomed. House Speaker Paul Ryan, R-Wis., made repeal an early order of business in the new Congress, but his first attempt at passing an Obamacare replacement was rejected, mostly because conservatives believed it retained too much of the ACA.
Ryan made changes to mollify the conservatives and pushed a second version through the House. But the bill, in addition to containing Medicaid provisions onerous to states, opened the door to scrapping a popular feature of Obamacare: a guarantee that people with pre-existing medical conditions cannot be denied affordable health insurance.
The House bill was dead on arrival in the Senate.
McConnell then took over. He bypassed committees that normally deal with health policy and named 13 senators to draft a bill in secret. The product of this dubious process was a bill that would have eliminated taxes on the well-to-do imposed by Obamacare to finance insurance subsidies for low-income Americans.
When it became clear this bill lacked sufficient support, McConnell offered another version that retained the taxes and tried to woo recalcitrant senators with additional money — not enough, his critics said — to help states combat opioid abuse. Alaska was given special benefits in an effort to win over Sen. Lisa Murkowski, a skeptical centrist Republican.
Despite these provisions, Kasich said, states were still short-changed on Medicaid.
Ultimately, the replacement measures were top-down efforts that collapsed from their own weight. Neither Ryan nor McConnell allowed a hearing on any of the bills. (There were more than 40 hearings before the ACA was passed.)
As Norm Ornstein, a veteran congressional watcher observed in The Atlantic, this approach shut out “those on the front lines of health policy and delivery, including doctors, hospitals, insurers, nurses (and) those with debilitating diseases …”
It also shut out the states, but the Republican governors managed to get their voices heard.
McConnell said he will now seek a vote on a bill to repeal the ACA in two years, giving Congress that much time to find a replacement. This would cause “turmoil” in insurance markets, Collins said. She, Murkowski and Sen. Shirley Moore Capito, R-W.Va., joined in opposing the McConnell proposal, ensuring its defeat.
“I did not come to Washington to hurt people,” Capito said.
According to the nonpartisan Congressional Budget Office, 17 million people would lose health insurance next year if the ACA is repealed without replacement.
But it’s no time for Obamacare supporters to pop champagne corks. Trump said after rejection of the BCRA that “we’ll let Obamacare fail, and then the Democrats will come to us.”
Because of an ironic overreach by Obama, Trump could make his prediction a self-fulfilling prophecy. After Congress rejected Obama’s request for funds to subsidize deductibles for the poorest ACA recipients, Obama paid the subsidies anyway in monthly payments to insurance companies, which in turn paid for the deductibles.
The House then sued Obama for spending $175 billion on subsidies unauthorized by law. On May 11, 2016, a judge ruled in the House’s favor. The Obama administration continued the subsidies, pending an appeal that has yet to occur.
The Trump administration has also paid them while Congress considered an Obamacare replacement. Should he decide to discontinue the payments, the ACA would face a crisis.
Even if Trump decides not to undermine the ACA, the law has problems that must be addressed. It does not provide sufficient funds for addiction and mental health services. It has strained insurance markets, prompting several companies to withdraw from state ACA exchanges.
Reduced competition means higher premiums. The problem is acute in rural areas. One analysis says that 1,370 counties will have only one ACA insurer in 2018 while 40 will have none.
Kasich followed up on his opposition to the Senate replacement bill by calling for bipartisan cooperation on legislation that would address the ACA’s shortcomings.
Writing in The New York Times, he said: “The best next step would be for members of both parties to ignore the fear of criticism that can come from reaching across the aisle and put pencil to pad on … ideas that repair health care in real sustainable ways.”
The states should be a part of this process.
— Lou Cannon, a Summerland resident, is a longtime national political writer and acclaimed presidential biographer. His most recent book — co-authored with his son, Carl — is Reagan’s Disciple: George W. Bush’s Troubled Quest for a Presidential Legacy. Cannon also is an editorial adviser to State Net Capitol Journal, which published this column originally. Click here to read previous columns. The opinions expressed are his own.
