Even if Republicans pass 'skinny repeal,' their health-care push is most likely doomed

The Republicans' great quest to kill ObamaCare has finally reached its endgame.

A Tuesday vote kicked off a legislative free-for-all, in which Senate Republicans will write their health-care bill by throwing stuff at the wall and seeing what sticks. That process will conclude any day now. And it looks like Senate Majority Leader Mitch McConnell already knows what the final product will be: the so-called "skinny repeal" bill.

Exactly what will be in the skinny repeal is still in flux. But the basic idea is minimalism: Stick to killing the limited parts of ObamaCare that are broadly unpopular and that most Republicans can agree they want gone. That would undoubtedly include scrapping the tax penalty that enforces ObamaCare's individual mandate. Other potential targets are the law's employer mandate and some of its taxes, as well as defunding Planned Parenthood and some sort of waiver to let states get out of certain regulations.

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But even that lowest common denominator effort may not pass.

First, McConnell seems to have lost two GOP senators entirely. That gives him absolutely zero margin for error. He can't lose anyone else.

Second, Republicans are using a procedural move called "reconciliation" to move the bill through the Senate. It allows passage with simple 51-vote majorities, dodging the filibuster's 60-vote requirement. That allows Republicans to avoid any need to negotiate for Democrats' votes. But bills passed by reconciliation must restrict themselves to fiscal policy. And major parts of the proposed skinny repeal bill — like defunding Planned Parenthood and the regulatory waivers — have already been shot down by the Senate parliamentarian on those grounds.

On top of that, reconciliation bills must meet certain budget saving requirements. But most of the provisions under consideration for skinny repeal would lose the government revenue and expand the deficit. So that's giving the Republicans headaches too. And they have very little time left to sort it all out.

But let's say McConnell can jam together a version of skinny repeal that both passes muster with reconciliation and can pass the Senate. That still doesn't solve his most fundamental problem.

Without a doubt, President Trump would sign whatever trainwreck of an ObamaCare repeal bill the Republicans can get to his desk. But to actually do that, the House and the Senate must agree on one final legislative text. More specifically, the Republicans in the House and the Senate must agree on one final text. Democrats understandably won't be helping them.

Yet the version of TrumpCare the GOP managed to pass through the House looks nothing like the Senate's developing skinny repeal bill. The hardcore conservatives among House Republicans are well aware of this, and they're already saying skinny repeal won't cut it for them. Meanwhile, the closest thing the Senate has to the House version of TrumpCare is the version McConnell and his lieutenants spent a few months crafting — and that failed spectacularly on Tuesday, with nine Senate Republicans jumping ship.

So the party has yet to come up with any sort of bill that workable majorities in the House and the Senate can agree on. Their best hope now is that the raw peer pressure to pass something, anything, is enough to keep everyone in line.

At root, the GOP's problem is this: Americans want lower premiums, lower deductibles, generous coverage, and less hassle overall from their health insurance. In fact, Medicaid is strikingly popular with the general public — much more so than the private plans sold on ObamaCare's exchanges — for precisely these reasons. But achieving any of those results requires some combination of tighter regulation on private insurance and more government spending on either premium subsidies or Medicaid or both. And "more regulation and more spending" is precisely what the GOP is dead set against.

There is no way for the party to deliver the health-care results voters want while also sticking by all its ideological priors. It cannot be done. Something must give. This has always been the existential crisis at the heart of the GOP's long quest to kill ObamaCare. And the GOP has never squarely faced it. Everything the party has done until now — including McConnell's supposedly brilliant procedural stratagems — has been one long exercise in delaying that final and inevitable reckoning.

That contradiction has also forced the Republicans into relentless deception throughout this entire drama. They've ripped ObamaCare for rising premiums and higher deductibles, then pushed a set of policy changes that would make those problems worse. They've indulged in a partisan closed-door process far worse than the most absurd caricatures of ObamaCare. They've claimed massive cuts to Medicaid won't result in coverage losses for its beneficiaries. Supposedly principled moderates like John McCain have slammed their own party's bills on substantive and procedural grounds — and then voted for them anyway.

The skinny repeal is of a piece with this nonsense. Let's say it's just a placeholder, to be replaced by totally new legislation when the Senate and House meet in conference. The most likely end result will be something close to the previous versions of TrumpCare, complete with higher premiums, higher deductibles, less aid for Americans, and massive cuts to Medicaid. All of which the Senate's moderate Republicans are already on record opposing. On the other hand, if skinny repeal itself actually became law, it would destabilize the individual insurance markets and cause premiums to spike — precisely the result Republicans say they're trying to avoid by repealing ObamaCare.

Either way, there's no reason the GOP moderates should sign on. Skinny repeal won't go anywhere that's consistent with their expressed values. Yet it may very well squeak through the Senate, because in the end skinny repeal is just one more desperate attempt to kick the can a little further down the road.

But ultimately, the Republicans must either commit themselves to a monstrous bill Americans will hate or abandon their quest — and thereby confess that their seven-year campaign against ObamaCare, and all their promises of something better, was nothing but showboating and snake oil salesmanship. Those are their only two options. There are no others.

And very soon, the GOP will finally have to pick.