As the second attempt to find 216 votes for the revised AHCA failed for now, I wanted to write a bit about the reasons I think it is so difficult while looking at history for healthcare in both parties.
I think the problem of having no goal regarding Healthcare is not new to the GOP and hugly problematic now that they have to pass a bill. If you look at polls democrats care a lot more about healthcare in comparison to republicans over a long period of time. There is a reason Bill Clinton tried to pass Hillarycare and in 1993 passed CHIP as a small measure. In 2008 Obama and HRC had whole debates where they talked mostly about healthcare. Universal Healthcare/Single Payer has been a rallying cry on the left for decades.
So in 2009/10 when they passed Obamacare there were decades of expectations and a base that cared about this topic to power through difficult stretches and take political painful votes. Remember just how often it seems that the ACA was dead and still they find a way to move on and pass it in the end. The results they tried to achieve(covering more mostly low-income people, banning discrimination for pre-existing condition, children staying on their parents plan until 26 and Essential Health benefits) matched what the base wanted and these goals are broadly popular. The tradeoffs to reach these goals are of course a lot less popular (new taxes, the mandate).
There is nothing like that on the conservative/republican side. Republican voters and politicians care a lot less about healthcare. What conservative think tanks produce regarding healthcare policy finds little resonance with elected republican members. Just remember Medicare Part D, which had very little to do what most conservative healthcare experts wants to do with the Healthcare System and was pushed by a republican president. Medicare Part D polled well and is a good way to get re-elected by high-turnout seniors but is not conservative.
Republican politician mostly ignore healthcare or take the most politically advantageous position in the short term, as there is no ideological basis most republicans are following unlike for example taxes.
You could see that in the way Republicans ran against Obamacare, they rightful attacked the many problems this law has and calling for repeal was always a crowdpleaser. But I can’t remember one prominent politician who tried to convince the public that the benefits of Obamacare(pre-existing, kids can stay in their parents plans, more people covered) are not worth the heavy price we pay for these advantages. You saw that in polling where obamacare was quite unpopular but these benefits polled very well.
There were outside republican groups who aired spots where voters were promised that republicans had a plan with more choice, lower premiums and protection for people with pre-existing conditions, which is simply not possible. Trump of course was the worst offender but there were a lot of moderate republicans who promised the upsides of Obamacare without the unpopular parts.
With this background after Trump won the house republicans had to write a bill that could get 216 votes,while having the following problems:
- No clear ideological goal they could use a guiding principle for the bill
- Having to work under reconciliation rules
- Having to break a lot of promises either way because it is impossible to fully repeal Obamacare and keep all the ACA benefits
- Members(especially moderate members) who have little appetite for political painful votes and little pressure by the base to force them
- Obamacare and it’s benefit getting more popular as repeal got closer, even with republican voters
- An unexperienced administration and Trump who more cared about a win than the details of the bill
WIth all that is it really surprising that the AHCA is so unpopular and difficult to pass?