Politics. Despite being warned of its evil since childhood, the Republican party allowed resentment to animate its strategy for over a decade. The Affordable Care Act was a loss from which they were slow to recover, becoming their “lost cause” from 2010 until last week.
It is not just the principles on which the law rests – government mandates, transfers and protectionism – but the way in which it made its way to President Barack Obama’s desk that has been the irritant.
With a bare majority in the Senate, Democrats used budget reconciliation in a novel way to pass a massive spending and policy bill. Republicans never saw it coming. They were snookered and that sting informed their priorities for years.
And it hijacked former President Donald Trump’s.
No more. Last week the former and potentially future president declared repeal of the ACA as off limits in his policy priorities. There are no pending proposals, but the ill-fated 2017 attempt leaves him open to claims he will try again. It also sends a signal to Congress and candidates that they should leave the issue alone.
It is, as we say, good politics. Forgotten in these years of late cycle political alignment is the eternal lesson of taking your losses and living to fight another day.
Policy. It is now a bipartisan view that the ACA has contributed to market consolidation and sector inflation that few find acceptable. The binary choice between repeal and preservation has left little room for agreement, at least not in public.
Having eliminated the most drastic option, repeal, what could threaten the status quo? The most obvious target is the MCOs. They know it and Congress knows it. Shareholders know it too.
Given the white-hot attention on the subsector, we should not discount a little political theater. Talking up their benefits cost (which appears to be very real on the inpatient side) helps neutralize the excessive margin argument. It also deflects incoming from the hospital lobby over prior authorization and other tricks of the health insurance trade.
Regardless, the fix, if there is one, is going to be Congress’ problem no matter who the next president is.
Power. Mr. Trump’s declaration suggests something probably no one wishes to discuss. Perhaps, the candidate is approaching the job of presidency with a bit more seriousness than in 2016.
Public policy is not easy. Health care is probably its toughest neighborhood. It is characterized by near uniform opinions about problems and solutions, all of which conclude with spending more money.
Republicans’ attempt to repeal the ACA in 2017 dragged then President Trump into a political defeat that was easily avoided by first, not trying and second, not leaving it up to Mr. Trump’s nemesis, the late Senator John McCain.
More than anything the long-sought repeal of Republicans, especially on the House side, was borne not out of policy considerations – although there are many – but a need for vindication and retribution for the ACA’s slick move through reconciliation.
It was not Mr. Trump’s fight. He had been a registered Republican all of six months when the ACA passed. It showed in the failure to develop an alternative vision and propose new possibilities, leaving that to a Congress just out for blood.
Well, he won’t be making that mistake again.
Have a great rest of your weekend.
Emily Evans
Managing Director – Health Policy
X
(Politics, Policy & Power is published in the quiet of Sunday afternoon or holiday Monday and attempts to weave together the disparate forces shaping health care. It makes no attempt to defend or prosecute the views of any established political party or cause. Any conclusions to the contrary rest with the reader alone.)
