When Republicans unexpectedly captured the White House and retained the Senate in November, Speaker Paul Ryan (R-Wis.) wanted to capitalize on the GOP’s political momentum right away by quickly passing a straight ObamaCare repeal bill similar to the one that passed both chambers of Congress at the end of 2015.
Option B was legislation that repealed and replaced the landmark health-care law.
Ryan and Senate Majority Leader Mitch McConnell (R-Ky.) preferred option A because they knew it would be a tough battle to unify the party behind a plan that would keep some of ObamaCare’s insurance subsidies and regulatory reforms in place.
They also thought it wise to set up a two-year transition period to come up with a replacement.
{mosads}A source familiar with discussions between the White House and GOP congressional leaders said that President Trump initially sided with Ryan and McConnell, believing this would allow him to sign a repeal bill on Inauguration Day.
But Trump’s advisers worried that repealing ObamaCare without a replacement might backfire politically, according to the source.
Some of its provisions, such as the ban on insurance companies discriminating against people with pre-existing conditions and a massive expansion of Medicaid, were popular across the country.
Trump told CBS’s “60 Minutes” days after the election that he wanted repeal and replace done simultaneously.
“We’re not going to have a two-year period where there’s nothing. It will be repealed and replaced,” he said.
Trump’s position evolved under what some GOP leadership aides describe as pressure from conservative Sen. Rand Paul (R-Ky.), who initially expressed favor for enacting replacement reforms simultaneously with the repeal of ObamaCare.
A discussion with Trump shortly after Christmas sealed the health-care strategy, according to a person whom Ryan later briefed on the conversation.
Trump told Ryan that he wanted a bill that simultaneously repealed ObamaCare and created a replacement program to mitigate the impact on millions of Americans at risk of losing health insurance, the source said.
Trump underscored his views shortly after the interaction when he warned congressional Republicans over Twitter to be careful about repealing ObamaCare so the GOP would not be blamed for any turmoil that might result from scrapping its insurance subsidies and Medicaid expansion.
“Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases,” Trump tweeted on Jan. 4.
“Don’t let the Schumer clowns out of this web,” he added, referring to the Senate Democratic Leader Charles Schumer (N.Y.).
What followed was a nine-month odyssey filled with ups and downs and ultimately a failure for Trump and Republicans.
Not just Trump
It wasn’t just Trump who fled from the idea of the repeal-only strategy.
When McConnell proposed the straight repeal bill at the first Senate Republican chairmen’s meeting in January, he was met with unexpected pushback from his colleagues, according to a senior GOP aide familiar with the meeting.
“He was astonished when several chairmen said ‘I’m not going to vote for that,’” the aide said.
A Republican chairman who attended the meeting recalled McConnell giving a soft sell, presenting repeal-only as a possible avenue for action. The chairman said it was clear after reviewing data provided by the Centers for Medicare and Medicaid Services and a major private insurance company that a replacement would have to be passed at the same time as a repeal.
“Otherwise it would have just been an amputation,” the Republican senator said.
Some Republican strategists now think in retrospect that party leaders erred by not using the political momentum from the election to quickly push a repeal-only bill.
“The first error was not pushing immediately out of the gate to pass the bill that they previously passed. If you pass that bill with the transition period of some sort then you can have a debate over regulatory reform. It’s a different environment. It’s a much better position for Republicans to be in,” said James Wallner, a former senior Senate Republican aide.
Other Republicans think Trump and GOP leaders made a mistake right off the bat by trying to tackle as huge as comprehensive health-care reform on a partisan basis.
Once Republicans settled on repeal-only, Ryan and McConnell knew they had little margin for error. In the Senate, the GOP controlled 52 seats and could afford only two defections.
GOP leaders thought they could push a complex bill to repeal and replace ObamaCare through Congress quickly.
The budget resolution that Senate Budget Committee Chairman Mike Enzi (R-Wyo.) initially unveiled instructed the committees of jurisdiction to draft reconciliation bills by Jan. 27.
McConnell told The Hill in an interview in late January that he wanted to wrap up the health-care debate “very quickly,” warning, “I don’t think we have the luxury of this dragging out for a lengthy period of time.”
That turned out to be a miscalculation.
Delays, delays
The repeal-and-replace bill became mired in a drawn-out process that chewed up months of the legislative calendar.
Political momentum behind health-care reform faded over February and March amid haggling over legislative details.
The House Ways and Means Committee did not mark up its health-care bill until after the first week in March.
Republicans didn’t have a ready-made plan to replace ObamaCare because they didn’t think Trump would beat Hillary Clinton.
Ideological disagreements between moderates and conservatives flared up, and Ryan realized shortly before the House bill came to the floor in late March that he didn’t have enough votes.
But Trump was eager for a big legislative victory and pressured Ryan to bring it up for a vote anyway.
The president gave wavering GOP lawmakers an ultimatum a day before the scheduled vote — planned for March 24 — by telling them it was now or never.
Republicans had “one shot” to repeal ObamaCare, he told conservative defectors in one meeting.
To avert a public relations disaster, Ryan had to drive over to the White House on the day of the vote to tell Trump that the bill could not pass.
Trump was furious, but there wasn’t much he could do.
The legislation appeared to be dead as Congress left for the two-week Easter recess.
New life
The bill got a new shot of life, however, days later.
Rep. Mark Meadows (R-N.C.), the chairman of the conservative House Freedom Caucus, announced he was pursuing a deal with Rep. Tom MacArthur (R-N.J.), the co-chairman of the moderate Tuesday Group.
The duo announced an agreement in late April to revise the bill to allow states to opt out of some of ObamaCare’s regulatory requirements.
GOP leaders secured the vote of another moderate leader, Rep. Fred Upton (R-Mich.), by adding $8 billion in funding to cover some of the insurance costs of people with pre-existing conditions.
The House finally passed its ObamaCare repeal-and-replace bill on May 4.
It was months behind schedule, but an ebullient Trump hailed it as a major victory. He marked the win with a Rose Garden ceremony, an unusual honor for a bill that had passed only one chamber.
Battle moves to Senate
Unfortunately for Trump, the changes that helped win over House conservatives alienated Senate moderates.
Sen. Susan Collins (R-Maine) declared the House bill a non-starter and warned that regulatory waivers for states would likely make coverage unaffordable for people with pre-existing conditions.
“The Senate is starting from scratch,” she declared. “We’re going to draft our own bill.”
Looking to make up for lost time, McConnell hoped to bring health-care reform straight to the floor after negotiating the outlines of the bill at meetings of a special 13-member group he appointed.
Republican senators say that turned out to be a mistake.
“We should have had hearings and an open process. Then the American people would have understood better what was the intent of the legislation to improve their situation, their premiums and deductibles,” said Sen. Rob Portman (R-Ohio), who held back his support for weeks because of concerns that proposed cuts in Medicaid would hit his home state especially hard.
McConnell’s decision to set up a special working group immediately ran into controversy because he didn’t formally name any women to the group. The House proposals to defund Planned Parenthood and allow states to obtain waivers exempting insurers from federal requirements to cover maternity care were particularly unpopular with women.
One Republican senator said it appeared that McConnell expected his conference to rally behind the House bill after it was revised and did not intend to start “from scratch,” as Collins and other GOP senators wanted.
“I think a lot of it was our leadership thought the House bill would be taken up, and it turns out a lot of us didn’t like the House bill,” said the lawmaker who requested anonymity.
“It didn’t work out the way they assumed, yet they didn’t make time to have a regular process,” the source added.
A Senate bill
Senate leaders released their draft legislation, the Better Care Reconciliation Act, on June 22 after nearly two months of negotiation behind closed doors.
McConnell kept the details of the bill close to his vest before releasing it, prompting complaints from fellow Republicans that they had been cut out of the loop.
Conservative Sen. Mike Lee (R-Utah), whom McConnell named to the special 13-member working group, complained on Facebook that he was unaware of the bill’s details only days before its scheduled release.
“You cannot write the health-care bill, you cannot reform health care in this country within the Republican conference at lunch,” said Wallner, the Senate GOP aide.
McConnell was forced to postpone a vote on the Senate bill scheduled for late June after four conservatives — Sens. Ted Cruz (R-Texas), Ron Johnson (R-Wis.), Paul and Lee — criticized the bill for not doing enough to repeal ObamaCare’s insurance market regulations, which they said had caused premiums to spike.
Collins and other centrists also threatened to oppose a motion to even begin debating the bill.
Senate GOP aides at the time said the delay sapped the bill of critical momentum.
They also charge Trump with further undermining the measure by calling on the Senate to vote on a repeal-only bill, a sudden shift in messaging that gave conservative critics political cover for not supporting the repeal-and-replace bill.
McConnell and his allies scrambled to win over skeptical conservative and moderate colleagues by negotiating a series of last-minute revisions, including $70 billion in additional funding to stabilize shaky insurance markets and $45 billion to fight opioid addiction.
McConnell also scrapped language that would have cut taxes for high-income earners.
To woo Cruz and Lee, McConnell included language that would ease requirements on health plans as long as insurers offered at least one that complied with ObamaCare’s mandates.
The Senate votes
The bill suffered another damaging delay when McCain underwent emergency surgery in mid-July.
Even with more money and insurance reforms included, the bill still did not have enough votes to pass.
Collins was a firm no because of projections it would increase the number of uninsured Americans by 22 million over the next decade.
And Sen. Lisa Murkowski (R-Alaska) was concerned it would dramatically increase costs in her home state, which already has some of the highest health-care costs of anywhere in the nation.
When the bill finally came to the floor on July 25, McConnell barely had enough votes to begin debate. Vice President Pence had to break a 50-50 tie after Collins and Murkowski voted to block it.
The defections angered Trump, who lashed out at Murkowski the next day, tweeting, “Senator @lisamurkowski of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!”
Trump dispatched Interior Secretary Ryan Zinke to put pressure on Murkowski by threatening to end or curtail some federal programs important to Alaska’s economy.
The move backfired, according to Senate GOP sources, who say it only antagonized the fiery Alaska senator.
It soon became clear to GOP leaders that their repeal-and-replace bill didn’t have the votes to pass.
They then quickly tacked to promoting a so-called skinny ObamaCare repeal bill, which repealed ObamaCare’s individual and employer mandates, defunded Planned Parenthood for one year and gave states more flexibility to regulate insurance plans.
Many Republican senators didn’t like it, but McConnell pitched it as a strategy to begin a bicameral health-care negotiation with the House. The danger for critics of the measure was that the House might simply pass it — though Ryan assured worried senators that wouldn’t happen.
After days of frantic scrambling and last-minute talks, McConnell brought the skinny bill to the floor and appeared to have enough votes.
But the debate took an unexpected turn when McCain, in an after-midnight vote freighted with drama, gave the bill a thumbs down while McConnell stood a few feet away, his arms crossed and head bowed.
“While the amendment would have repealed some of ObamaCare’s most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality care to our citizens,” McCain said in a statement afterward.
McConnell conceded defeat on the floor.
“This is clearly a disappointing moment,” he lamented. “Everybody on this side can certainly attest to the fact that we worked really hard to try to develop a consensus for a better way forward.”
After weeks of fruitless bargaining, McConnell said, “it’s time to move on.”
A final stab
But it wasn’t over yet.
Senate Republicans took another stab at repealing and replacing ObamaCare in September, when Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) lobbied colleagues to support a bill that would have dismantled ObamaCare’s insurance subsidy program and Medicaid expansion.
Republicans felt pressure to pass something before a Sept. 30 deadline, at which point the special rules protecting their measure from a Democratic filibuster would run out. Anger from the GOP grass roots upset over the failure to fulfill a longstanding promise also played a role.
For a time, it appeared the measure had some momentum.
But then McCain and Collins came out in opposition over their concerns about a rushed process, the lack of Congressional Budget Office cost analysis and the lack of extensive committee hearings or debate.
Paul joined them, arguing the bill would leave too much of ObamaCare in place by simply converting its funding into state block grants.
The bill was also hurt by the opposition of late-night host Jimmy Kimmel, who accused Cassidy of lying about his pledge to support legislation that would cover the cost of young children regardless of their families’ ability to pay for it.
Graham and Cassidy admitted defeat Tuesday but vowed to take up the fight again after the tax-reform debate, which is next on the congressional agenda.
The draft budget resolution unveiled Friday did not include any specific instructions for health-care reform, however, which means the battle to repeal ObamaCare will wait until 2019 or later.
Tougher than expected
Some Republicans now believe they underestimated how tough it would be to repeal ObamaCare. They misjudged the complexity of the issue and ideological divisions within their party.
Sen. Shelley Moore Capito (R-W.Va.) said lawmakers needed more time to resolve the conflicts between lawmakers representing states that opted to expand Medicaid under ObamaCare and those that didn’t.
West Virginia expanded Medicaid enrollment under ObamaCare’s generous funding scheme, and Capito worried that cutting back federal resources would cause budget problems at home.
“What needed more time and study was the expansion-,non-expansion-state issue. You could see a divide developing there,” she said.
“I think it was underestimated how difficult it would be,” she added.
GOP strategists say the party embraced the promise to repeal ObamaCare before it was implemented and became ingrained in the fabric of the nation’s health-care system.
“We went from opposing a major change in the status quo to proposing a major change in the status quo,” said strategist Vin Weber.
Once people began adapting to the law and relying on it, Republicans faced an uphill battle in getting rid of it, Weber argued.
“The American people may gripe about the health-care system, but they really rebel against the notion that the government is going to make a major change to it,” he added. “Big change in the health-care system is unpopular with Americans because it means they’re going to have to change one of the fundamental areas of their lives.”
Other lawmakers insist the fight isn’t yet over and believe the debate will resume before next year’s election.
“We’re not finished yet. We’ve got to keep at it. We cannot give up,” said Cruz. “We’re closer than many outside observers think.”