There were so many reasons for the failure of the Republicans’ health care bill — and its failure was so spectacular — that it’s hard to tell which ones mattered most. The bill was poorly drafted and lacked buy-in from key Republican stakeholders. President Trump’s boardroom negotiating tactics didn’t translate well to the halls of Congress. The House Freedom Caucus was intransigent; it represents a new axis of conflict within the GOP, and House Speaker Paul Ryan didn’t have a good plan for handling it.
Any of these factors alone might have scuttled the bill; health care legislation is never easy. Taken together, they not only doomed the bill but imploded it. Republicans had promised to repeal the Affordable Care Act for seven years; their bill didn’t survive for three weeks.
But the variety of unforced errors by Ryan, Trump and other Republicans obscures other, more fundamental problems with their health care bill. Namely, the American Health Care Act was a fairly radical piece of legislation and — perhaps relatedly — an exceptionally unpopular one. The public may have wanted change when they elected Trump, but this was not the sort of change they were looking for.
The AHCA wasn’t radical in the way a Freedom Caucus-designed bill might have been. It didn’t dismantle Obamacare’s exchanges. It wouldn’t have allowed insurers to deny coverage on the basis of pre-existing conditions. Philosophically, it didn’t do much to challenge former President Barack Obama’s notion that Americans had a right to health insurance and that government had a duty to ensure its availability. For these reasons, Freedom Caucus members and libertarian-ish Republicans complained that the bill didn’t go far enough.
But the bill had huge redistributive effects. The AHCA would have cut taxes by almost $600 billion over a decade, but almost all of the reductions would have been realized by people making at least $200,000 a year and much of it by people making $1 million a year or more, according to the Joint Committee on Taxation. By contrast, insurance premiums would skyrocket for older, poorer Americans. On average, a 64-year-old with an annual income of $26,500 per year would have to pay about $14,600 to purchase insurance on the exchanges, according to the Congressional Budget Office.
Obamacare, of course, also represented a significant wealth transfer — from wealthier toward poorer Americans. But it also made significant reforms to the health care system. Roughly speaking, the AHCA would have reversed as much of the wealth transfer as possible while leaving the rest of Obamacare relatively intact. One can reasonably argue that it wasn’t a health care bill so much as a tax cut for high earners that used cuts to Medicaid, and reduced subsidies on the insurance exchanges, to pay for itself.
Whatever it was, it didn’t make for a popular approach. I calculated last week that the AHCA was unpopular even in most Trump-voting, Republican-held congressional districts. And that was before the release of a Quinnipiac University poll showing only 17 percent of Americans supporting the bill against 56 percent opposed. It’s not clear whether the Quinnipiac poll was an outlier — other polls haven’t been quite as bad for the AHCA — or a sign that the bill was growing even less popular as the debate on it continued. But it’s unusual to see such lopsided numbers in an era of intense partisanship, when public opinion on many issues is divided about 50-50 or perhaps 55-45 in one direction. Americans were unusually unified in their dislike of the GOP’s legislation, and Republicans and Trump ought to have taken some signals from that.
It’s hard to say how much those polling numbers — and other signs of public disapproval, such as letters and phone calls from constituents to their members of Congress — affected the bill’s chances for passage. While most reporting has focused on the House Freedom Caucus’s objections, the AHCA also faced significant dissent from moderate Republicans, perhaps enough to kill it.1 And considering that the bill would almost certainly have faced resistance from moderates in the Senate even if it had passed the House — and that no Democrats in either chamber had pledged to support it — the narrative that the Freedom Caucus was principally responsible for the bill’s demise is at least a little dubious.
The more fundamental, Politics 101 problem is that Ryan drafted a bill that was too far removed from what voters actually wanted. If the bill wasn’t killed by moderate Republicans, it was probably going to exact a significant electoral penalty on the GOP, like the one Democrats endured after passing Obamacare in 2010.
And then there’s Trump. His philosophy toward the size and scope of government has never been clear, exactly. But from the hints he’s given — such as in advocating for a trillion-dollar infrastructure plan — he tends more toward the center than either the Ryan or the Freedom Caucus wings of the GOP.
Trump was elected without much of a mandate, given his narrow margin in the Electoral College and his loss in the popular vote. But congressional Republicans didn’t have much of a mandate, either. Although people seemed to forget about it as they focused on Trump’s upset win at the top of the ticket, Republicans lost seats in both the House and the Senate in last year’s elections.
How many congressional seats a party gains or loses when it takes over the White House is a good measure of whether there was an overall mandate for the party’s agenda or instead the presidential result reflected a more incremental (and perhaps quirky or circumstantial) victory. Among the 11 times in the past century when the presidency changed parties, Warren G. Harding in 1920, Franklin D. Roosevelt in 1932, Ronald Reagan in 1980 and Barack Obama in 2008 all came into office with major gains for their party in Congress and a lot of wherewithal to enact sweeping changes. Trump, George W. Bush, Bill Clinton, Jimmy Carter and John F. Kennedy did not, by contrast. Dwight Eisenhower and Richard Nixon were somewhere in between.
|1920||Warren G. Harding (R)||+61||+10|
|1932||Franklin D. Roosevelt (D)||+97||+11|
|1952||Dwight Eisenhower (R)||+22||+1|
|1960||John F. Kennedy (D)||-22||-2|
|1968||Richard Nixon (R)||+5||+6|
|1976||Jimmy Carter (D)||+1||0|
|1980||Ronald Reagan (R)||+34||+12|
|1992||Bill Clinton (D)||-10||0|
|2000||George W. Bush (R)||-4||-2|
|2008||Barack Obama (D)||+21||+8|
|2016||Donald Trump (R)||-6||-2|
Unsurprisingly, there’s a correlation between a party’s gains or losses in Congress and the margin of its presidential victory. But it isn’t a perfect one. Clinton won the Electoral College fairly definitively in 1992, but his Democrats lost nine seats in the House and only broke even in the Senate. Eisenhower’s congressional gains were modest given his landslide presidential victory, meanwhile. You could interpret that as meaning Eisenhower and Clinton were elected more on their personal qualities — Eisenhower’s résumé, Clinton’s personality — than on the basis of their party’s agendas. And that was reflected in the policies they pursued. Eisenhower was one of the most centrist presidents of all time, while Clinton ran — and mostly governed — as a “New Democrat,” somewhat against his party’s tax-and-spend reputation.
Trump isn’t in the Eisenhower or Clinton category because his own electoral performance was underwhelming, just as his party’s was in Congress. Instead, the better comparison is to George W. Bush, who like Trump lost the popular vote and also saw his party lose seats in Congress. But Bush also governed in a fairly bipartisan fashion early in his term2 before moving to the right after the Sept. 11 attacks.
Instead of offering a centrist or a populist solution, however, the AHCA gave voters a bill that nobody was asking for. Republicans have been running on repealing and replacing Obamacare for seven years, and they’ve won a lot of elections in that period. You can argue that they have a mandate on the issue, even if they don’t have one overall. But Ryan and Trump pretty much ignored where public opinion stands on health care. Medicaid, which the AHCA would have rolled back, is extremely popular, for instance. About two-thirds of voters support government funding for Planned Parenthood; the AHCA would have cut it. But the bill didn’t do much to address the problems voters were actually concerned about, such as rising premiums.
Furthermore, Ryan and Trump advanced this bill despite receiving a warning shot from the public: Obamacare had almost immediately become more popular after Trump won the election. I don’t recall a lot of other times when public opinion shifted so quickly on a bill in response to an election result.3 It was as though voters were throwing up a big yield sign to congressional Republicans — we didn’t expect Trump to win the election; instead, we elected you to serve as a check on Hillary Clinton, so proceed with caution. Ryan barreled right on through it.
Congressional Republicans could find themselves on similarly thin ice on tax reform and other major parts of their agenda. For instance, if they draft a budget that cuts taxes for the wealthy at the expense of programs that benefit the middle class, they might face another unpleasant choice between passing an unpopular bill or doing nothing and embarrassing their president.
Trump, however, has a few more options. Voters see him as comparatively moderate, and he won the Republican nomination despite defying Republican orthodoxy on issue after issue. Meanwhile, he’s threatened to collaborate with Democrats if Republicans can’t get their act together. Whether Democrats would reciprocate is another matter. But pursuing an authentically populist agenda — or if not that, an authentically popular agenda — might be one of Trump’s better options for salvaging his presidency.