The Real Story of Why Bipartisan Health Care Reform Is Impossible Now

Spoiler: It’s the Republicans. And a system in which all the political incentives—and especially for the GOP—are for stalemate.


This is making my brain melt. Not only can’t they keep their lies straight anymore, the Republicans; they just don’t even care that they can’t keep them straight. That’s, like, normal these days, for them.

Vox asked nine GOP senators what was in the new health care bill they want to vote on and couldn’t get straight or consistent answers. That’s normal too. And to round out the surreal new-normal trifecta, the health care experts agree that a late-night comic is more truthful and accurate about the bill than the United States senator who is one of its chief sponsors.

But then things got really weird when Charles Grassley accidentally blurted out the truth to The Des Moines Register: “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered. But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

What a proud moment in Senate history! Substance, schmubstance. We promised you no substance, just an empty posturing vote! Although in fact I remember the Republicans, and the guy who’s now president more than anyone, saying that they were going replace Obamacare with something better, more comprehensive, less expensive, and all around more beautiful. “We’re going to have insurance for everybody,” Donald Trump told The Washington Post in 2016. But every Republican plan that has come down the pike, including Graham-Cassidy, the current one, will toss millions of people off insurance.

Graham-Cassidy, vote allegedly coming next week, is the third stake Mitch McConnell’s Senate has tried to stab into Obamacare’s heart. They came up short the first time. Then they wrote a worse bill, and came up short again. Now they’ve written a still worse bill. And, because they are who they are, they may finally have found a bill mean enough and shallow enough to scare up 51 votes.

And here is what makes it all especially galling. While all this has been going on, there’s been a simultaneous serious effort underway in the Senate to come up with a bipartisan bill that would attempt to stabilize insurance rates, lower costs, and give states more flexibility while protecting the 10 “essential health benefit” categories of the Affordable Care Act. I think it’s slightly underappreciated how real this effort was, so here’s the story.

Tennessee Republican Lamar Alexander, who chairs the relevant Senate committee, and Washington Democrat Patty Murray, who’s the ranking Democrat, sat down a few weeks back to try to work something out. Their main goal was to strike a deal on the amount of federal money that would be needed, in the form of those now-famous cost-sharing reduction payments (CSR’s), to stabilize insurance rates for 2018. Those new rates get filed on Sept. 27, so that was their deadline. Each had other goals. Alexander wanted more flexibility in the way states could offer and regulate coverage, Murray wanted more federal assistance on “reinsurance,” which is complicated but is essentially federal money for plans that enroll high-risk customers.

The two of them huddled. Their committee… got to work! It held four hearings! With 20 witnesses! Governors, state insurance commissioners, health policy wonks, and so on. Hey John McCain, that sounds suspiciously like your beloved regular order! In addition, they invited senators from beyond their committee to attend informal negotiating sessions to see if there was any consensus to be found. They engaged about half the Senate. They were doing what these people are supposed to be doing.

But then they hit some snags. Murray wanted a multi-year commitment on the CSR’s; Alexander said he could only sell his caucus on one year, and he wanted a simple bill because that Sept. 27 deadline loomed. The bigger issue was the state flexibility thing. And here, Murray made a big concession Monday night. It’s awfully wonky (read more here if you like) but it has to do with granting waivers to states to allow greater innovation to try to encourage the use of lower-cost services and discourage the use of high-cost services.

And then they hit some bigger snags, known by the names of the Trump administration, Paul Ryan, and Mitch McConnell. Tuesday morning, the White House said forget this bipartisan nonsense, and the speaker said he’d bury it in the House anyway. McConnell said little publicly, as is his style, but it is widely thought that privately he told Alexander to drop it. Whether that did or did not happen, Alexander dropped it. He announced Tuesday that the process was over for now. Murray’s statement read in part: “Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a partisan Trumpcare bill.”

I realize that telling you that bipartisanship failed has roughly the news value of telling you that Mel Gibson has issues. But it’s worth thinking about in historical context.

Thirty years ago, the Alexander-Murray effort would have been where the action was. There would have been a handful of Democratic senators from states like, well, Alexander’s Tennessee, which in point of fact had two Democratic senators 30 years ago (Jim Sasser and that guy named Gore). There would also have been a few Republican senators from states like, well, Murray’s Washington (one of whose senators in 1987 was indeed a Republican, Slade Gorton). There would have been a Republican leader of the House, Bob Michel of Illinois, who was fairly moderate and whose caucus included a large number of moderates, and who never would have said to senators that any bipartisan thing you pass will never see the light of day on my side of the Capitol.

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And, there are some things that would not have been the case. In 1987, Republican lawmakers weren’t living in fear of the likes of Rush Limbaugh and Alex Jones, whose YouTube page as I write this features a video defending Jones’ claim that gay frogs are real. And in 1987, Republicans were allowed to discuss tax increases, as this was before Grover Norquist started enforcing his pledge, and weren’t yet slavishly devoted to slashing taxes for rich people, which is part of the long-term GOP health care “reform” plan.

Too often, when people talk about polarization, they speak as if it’s just a matter of will on the parts of these lawmakers. It’s not. It’s a matter of the institutional structures and forces at play. In 1987, the incentives existed for lawmakers to compromise. Now, all the incentives, especially on the Republican side, are for stalemate.

I give Alexander credit for trying. On the other hand, he’s in all likelihood going to vote for that bill next week, a bill he surely knows to be an irresponsible mess. And the Sept. 27 deadline will pass with nothing having been done to stabilize the premium rates that real people really pay. I assume that now, your brain is melting too.