Advancing a Free Society

The Health Care Repeal Vote: Fiction and Fact

Tuesday, January 18, 2011

The business of setting up a new Congress is finished and attention can now turn in earnest to making policy. For their part, the Republicans in the House have returned from the MLK Day holiday weekend and announced their intent to fulfill a GOP campaign promise: repeal and replace the health care reform law.

The House leadership’s decision to schedule debate on repeal of the Patient Protection and Affordable Care Act (PPACA) prompted Ezra Klein, a blogger at The Washington Post, to pen this post. In it, he provides his readers with an inaccurate description of the health care policy choices being taken up the 112th Congress. It is the kind of unhelpful commentary that erodes thoughtful public conversation about the direction of health care policy in this country and the real and difficult choices we will need to make. So Klein’s post has, in turn, compelled me to clarify the health care policy choices before the House and before all of us. For this post, I’ll leave aside my objections to Klein’s depiction of a health care system made much, much better by the PPACA and much, much worse should the bill be repealed. I’ll focus on what is actually being seriously considered on Capitol Hill in the near term.

A floor vote on repeal of the PPACA will not be, as Klein characterizes it, a choice between the PPACA (a laudable bill, in Mr. Klein’s view) and a return to the status quo in the health care system as it existed prior to the passage of the PPACA. This is true for several reasons, not least of which is that what Klein tries to portray as a real choice between two public policies is political theater. Klein knows it, and the members of Congress who will engage in the floor debate know it too. A floor vote that ends in passage of repeal in the House will not lead to the repeal of the PPACA. Full repeal of the PPACA will not make it through the Senate, where it would certainly be filibustered by some contingent of the 49 member Democratic caucus. As an extra measure of security for those who want the PPACA left intact, the House and Senate Republicans don’t have the two-thirds supermajorities required to override an inevitable presidential veto. For Klein to focus on the yea-nay roll call on repeal in the House without recognition of the larger context in which the Republicans have brought repeal to the floor is to obscure what’s really going on.

So what’s really going on? With a House floor debate and vote, Republicans are making a gesture to a segment of their constituents. These constituents, the political wisdom holds, sent them to Washington with a short list of specific To Do’s, one of which is to repeal the health care law. Whether that repeal is actually the policy change those voters want and whether lawmakers should be responsive to that group of constituents over others are questions worthy of thoughtful debate. But, whatever the case, the electoral strategy for the Republicans in the near term will involve showy legislative maneuvers in the service of “Repeal and Replace,” even though it’s no well kept secret that won’t be happening.

Klein also ignores the “and Replace” part of the GOP campaign mantra. Even if we play “What if?” and allow that the implausible scenario of full repeal has occurred, the chance of U.S. federal health care law returning to the prior status quo and staying there for the entirety of the 112th Congress, even its first session, would be vanishingly small.

There are a number of individual provisions of the PPACA that are popular with majorities of the American public. Three that top the list are the regulations on the insurance market to prohibit exclusions due to preexisting conditions, the end to lifetime benefit limits, and the ability to keep adult children on their parents’ insurance plans. These are among the features of the law that Klein calls out favorably in his post. They are also policies that were contained in the plan put forward by the Republican leadership during the 2009-2010 health care debate. Legislative aides on the Republican side would undoubtedly be ready to put some version of the previous Republican bill back in the hopper if the PPACA were repealed. Good policy aside, it would be smart political strategy as the Republicans move into the 2012 congressional and presidential election. They could pass popular policy that had the side benefit of hampering the ability of critics to paint them as the Party of No. Democrats and the president would feel immense pressure to support these modest reforms, especially as they had been part of the PPACA. Of course, legislative aides aren’t ready to introduce that Republican reform bill because the PPACA isn’t going anywhere anytime soon (and by that I mean at least until January 2013 when a new congress and, maybe, a new president will be sworn in).

But the House repeal vote will be more than campaign strategy. The repeal vote is an opening move in a legislative battle for piecemeal repeal of some individual provisions of the PPACA, reform of others, and probably some efforts to choke off funding for implementation in the appropriations process. Some of these small-scale changes to health care law are likely to win support from Democrats as well as Republicans. Although elimination of the individual mandate is probably a long shot, the 1099 tax form reporting requirement for businesses is vulnerable to repeal. It is widely regarded as an onerous regulatory burden on small business and was almost repealed during the last Congress with the Democrats at the helm. And the requirement that insurance companies must spend a certain amount of premiums on “direct medical benefits”? That provision of the law has created nothing but bad press for the Obama administration each time HHS Secretary Kathleen Sebelius grants another waiver for a company. (The most high profile case being McDonald’s and their mini-med policies.) Republicans are all for eliminating that requirement and Democrats could explain yea votes on repeal or modification of the law as a refinement that does not strike at the heart of PPACA.

Republicans lawmakers, or at least a governing majority of them, are not out to deregulate the entire health insurance industry, end Medicaid, pull funding from any and all cost containment experiments (a relatively minor part of the PPACA that gets big praise from Klein), or ban insurance exchanges (which existed in some states prior to the PPACA, by the way, although Klein suggests they were a wholesale new invention of the PPACA and would disappear if the PPACA were repealed). Republicans and Democrats disagree on central features of the new health care law, but claiming that Republicans are drooling at the prospect of complete retrenchment just isn’t the truth about what could happen under Speaker Boehner.

If liberal commentators want to have at the House Republicans, why not portray the debate over full repeal as a waste of precious legislative time, time that should be spent working on policy proposals that have some chance of passage and that address the real health care challenges in coverage, cost, and quality that remain before us? That’s an argument with some merit. Maybe it’s not one that political strategists already hard at work on Election 2012 will support, but it is one that American voters and policy wonks across the spectrum could embrace.

(photo credit: Medill DC)