A House Divided: The GOP’s Struggles to Repeal Obamacare

Just before 1:30am, on July 28th, 2017, Senator John McCain (R-AZ) shocked his colleagues and the American public when he voted against the Health Care Freedom Act (HCFA) and forcibly brought to an end the GOP’s latest attempt at repealing the Affordable Care Act (ACA), better known as Obamacare. As both Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) had already announced they would be voting against the HCFA, the GOP could not afford any more defections and Vice President Mike Pence was present to break the anticipated 50-50 tie. However, with McCain also voting against the bill, the ‘‘skinny repeal’’ was defeated 51-49, and the GOP came up short once again on their seven-year campaign promise to repeal Obamacare.

McCain’s ‘‘maverick’’ moment was pinpointed by many as the cause of this legislative failure on the Republicans’ part, but doing so would be ignoring the full picture. After all, earlier this month, Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) introduced another attempt to repeal Obamacare, but their proposed amendment did not even make it to a vote because three GOP senators had already come out against it. With the GOP in control of both the legislative and executive branches, it seems as their biggest obstacle to repeal Obamacare is not across the aisle, but within their own.

A Repeal Seven Years in the Making

Ever since the ACA became law seven years ago, the promise to “repeal and replace” it has been a key platform issue for the GOP. 2012 Republican Presidential Candidate Mitt Romney promised to repeal Obamacare on his first day in office, while President Donald J. Trump’s first 100 days objectives included the repeal of the ACA. Even Lisa Murkowski, who was one of the three senators to vote against the HCFA, was a stanch opponent of Obamacare, going as far as asking on the Senate floor in December 2015: “For whom is the Affordable Care Act affordable?”  But Murkowski is not the only Republican senator who has not been satisfied with the proposed repeal bills. In total, thirteen Republican senators have rejected at least one of the five main proposals.

The repeal saga started in the House of Representatives. In May, a small majority of representatives  (217-213) voted for the American Healthcare Act (AHA), a partial repeal of the ACA. The bill, under which 20 million people could lose insurance coverage, included the end of new enrolment under the Medicaid expansion and a repeal of employer mandates. The AHA was then sent to the Senate, where it only needed a simple majority to pass since it was considered part of the 2017 federal budget process (a provision only valid until the end of the 2017 fiscal year on September 30th). The first vote on an amended AHA, the first version of the Better Care Reconciliation Act (BCRA) did not take place as planned in June after four GOP senators had announced that they would oppose it. Later in July, a new version of the BCRA, now with a ‘’Consumer Freedom Option’’ amendment, was only able to gather the support of 43 senators, and thus failed to pass. Next up was another amended version of the AHA, the Obamacare Repeal Reconciliation Act (ORRA), a complete repeal of the ACA that was defeated 45-55 on July 26th.

After three consecutive failures, the GOP leadership was hoping that their next proposal, the HCFA, would fare better. It  was defeated in dramatic fashion, when John McCain voted against the bill alongside senators Collins and Murkowski. The clock was now ticking for Republicans. They had to come up with a plan that could gather the support of at least 50 senators before September 30th, after which a supermajority (at least 60 votes for) would be needed to repeal the ACA . Their last-ditched attempt was the Cassidy-Graham bill. The bill cut federal funding of 34 states, most significantly of California by $78 billion and New York by $45 billion. Like the other repeal plans, it aimed to transform the Medicaid expansion funds into block grants, which are huge sums of federal money with few strings attached, for states, though at a slower pace than previously proposed. It also allowed states to establish market rules that did not protect those with pre-existing conditions. The bill failed to gain the approval of a majority of senators, and thus it seems as if an Obamacare repeal is on hold for now.

Where Did it Go Wrong?

After the Republicans gained control of both the executive and legislative branches last November, the repeal and replacement of the ACA was high on their priority list. Given the Democrats’ minority status in both chambers, it seemed as if it was a done deal. However, they still have not repealed the ACA, and it must be examined why they have failed repeatedly if they still want to move forward with a future repeal.

One major problem the GOP senators face is that due to their slight majority in the Senate, they need to write a bill that will please at least 50 of the GOP Senators. In the event of a tie, VP Pence has the authority to break it in favour of the GOP. However, this has proved extremely difficult, given the vast spectrum of ideologies of Republican senators. Moderate senators, such as Susan Collins and Lisa Murkowski, do not seem to support any kind of repeal that includes cuts to Medicaid, a program that covers medical costs for people with low incomes. In the statement released after she opposed the Graham-Cassidy bill, Collins declared that cutting Medicaid funding ”would have a devastating impact” since it ”provides health care to our most vulnerable citizens”. Murkowski is not a fan of cuts to Medicaid, partially the Medicaid expansion lowered Alaska’s uninsured rate from 18.9 percent to 11.7 percent.  The most conservative Republican senators, like Rand Paul and Ted Cruz (R-TX), want to see a total repeal of the ACA, and none of the repeal bills went that far. Most proposed repeal plans, save for the ORRA, were middle ground compromises which aimed to satisfy everyone. Some senators were willing to support any piece of legislation in order to fulfill their campaign promise. One such example is Senator Chuck Grassley (R-IA) who declared before the planned vote on Graham-Cassidy that fulfilling his campaign promise was ‘‘as much of a reason as the substance of the bill.’’ However, others whose ideologies do not fall under this middle ground have not been willing to compromise on their beliefs.

Then why has John McCain, who is neither a moderate nor a libertarian but rather a conservative republican, voted against the last three proposed repeal plans? It seems as if ideological differences are not the only reason the GOP has been struggling with the repeal. McCain’s justification in voting against the various repeals does not come necessarily from the substance of the bills, but rather from the manner in which the legislation was drafted. After he voted against the HCRA in July, McCain strongly criticized the fact that the bill had drafted behind closed-doors by Republicans senators, and urged his colleagues of both parties to come together and work on a bi-partisan effort. After he announced his opposition to Graham-Cassidy, he once again urged that the next health care legislation be the ‘‘product of extensive hearings, debate and amendment’’.

Since the September 30th deadline has passed, it now seems that if the GOP still intends on fulfilling its campaign promise, it will need to listen to McCain’s plea and work with Democrats. In fact, the GOP now needs 60 votes to pass a healthcare reform, which means they will have to come up with a bill that not only has the support of all 52 Republican senators, but also eight Democrats. This will surely be an exhaustive process, since the GOP was not even able to get all of their own senators to agree on a piece of legislation. They could also abandon the idea, but given that a third of the Senate is up for re-election next year, it is a gamble. After promising to repeal Obamacare for seven years, Republican senators will now have to face their constituents and try to explain themselves.

Edited by Patricia Sibal