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.