The latest iteration of the Republican health-care bill is not going to become law.
But it's worse than that for the GOP. It's not just that this version of the plan to repeal and replace ObamaCare is clearly doomed. There is no iteration of a GOP health-care bill that is going to become law. Come 2020, President Trump will still be campaigning against ObamaCare as he runs for re-election.
The reason is clear: The divide between the Republican Party's moderates and right wing is just too wide. There is no piece of health-care legislation that can win the support of 50 of the Senate's 52 Republicans. This will almost certainly remain true even if the GOP manages to secure additional Senate seats in 2018.
The Senate's latest plan, like its various cousins, seems designed to please almost no one. Sure, people under the age of 27 will still be able to receive coverage with their parents' health-insurance plans. But older people not yet eligible for Medicare will have to pay more. The expansion of Medicaid will be allowed to continue as a quaint legal fiction but without the necessary federal funding. Insurance companies both will and won't be required to cover people with certain pre-existing conditions. In keeping with the best libertarian logic, yes, discrimination will be allowed — but it will be the voluntary kind, so no worries. Some rich people will continue to be taxed after all. At least Planned Parenthood will stop receiving federal funding for a whopping single year.
It's not particularly hard to see why the GOP's health-care push is such a mess. Paul Ryan and Mitch McConnell are backed into a corner. They cannot satisfy the right wing of their own party by actually repealing the Affordable Care Act because they are not stupid — or, I like to tell myself, cruel — enough to take health care away from millions of Americans. But they were happy to spend four election cycles raising money on the idea that decimating ObamaCare was their mandate. Now it's too late.
The Republican Party's core constituents, people who tended not to be affected by the law because they have salaries and generous employer-provided insurance, have no idea what Medicaid expansion has done for America's working class. (It has helped — a lot.) They aren't exactly sure what "ObamaCare" is, but thanks to Ryan, McConnell, and the rest of the GOP caucus, they regard it with loathsome horror — a strange attitude to take toward something so bloodless and wonky as the ACA.
The GOP leadership cannot please these people and simultaneously placate the handful of sober moderate voices in the party who say — quite reasonably — that while ObamaCare is miles from perfect, it would be politically suicidal and cruel to cleave out its most helpful measures in the name of tax-cutting or deficit-reducing.
And there's the bind. For right-wingers like Ted Cruz, or libertarians like Rand Paul, the Senate's bill contains a series of quasi-Stalinist intrusions into the ancient liberties of free men enshrined in our glorious Constitution, the sort of tyranny in defiance of which men bled at Bunker Hill and Yorktown (though Cruz will probably end up supporting it anyway, especially if it's clear that it's a dead letter). For moderates like Susan Collins, the bill is capricious, cruel, and unnecessary.
The gap between these two groups is unbridgeable, and unless Democrats lose an extraordinary number of seats in 2018, passing anything that would amount to the repeal of ObamaCare is going to be impossible as a matter of simple arithmetic.
It's hard to feel bad for Ryan and McConnell. If the Republican Party had been honest from the start about the pros and cons of the Affordable Care Act, it might have been possible to work with Democrats — who, when it is rhetorically convenient for them anyway — admit that ObamaCare is not without flaws and say that they are open to a bit of fine-tuning. But instead, Republicans have allowed ObamaCare to become a fetish object, a fell spirit that must be exorcised from the house that Jefferson and Reagan built.
This is where Trump comes in. Assuming he and the GOP majority survive in 2020, it will be up to him to seize upon his chance. He will have to stop playing footsie with the "conservative principles" in which he has never had any interest and speak clearly and honestly with hardline conservative voters about the ludicrous nature of our pseudo-insurance public-private hybrid system.
Would a single-payer bill that does not fund contraception or abortion be able to carry the House and the Senate with Democratic votes? That would be an interesting test for the leadership of another cynical political party that uses bogeyman issues to inflame its base at the expense of the common good.