SPAA Professor Frank Thompson Responds to Failed Affordable Care Act Repeal Attempt

On Friday, March 24, the Republican-sponsored American Health Care Act that was proposed in an effort to repeal the Affordable Care Act was withdrawn before going to a vote in the House of Representatives. The withdrawal was the result of lack of legislative support that signaled divisions within the Republican Party on the government’s approach to health care. The development ended weeks of political debate, protests, and negotiations among those who support the continuation of the current Affordable Care Act and those who support its repeal. We asked Board of Governors Professor of Public Affairs and Administration Frank Thompson to weigh in on the recent health care conflict. Thompson is a nationally renowned scholar of politics and administration, policy implementation, public management, federalism and intergovernmental management, and health policy.

What do you consider to be the primary reasons why the American Health Care Act failed to go to a vote?

I think there were a number of factors involved here, but a few really strike me. The first issue is the fragmentation of the Republican Party, but more specifically, the ideological rigidity and fervor of the Freedom Caucus in the Republican Party. The Freedom Caucus essentially killed this measure and as House Speaker Paul Ryan said, Obamacare is here to stay for the foreseeable future, and it’s quite a striking development in American politics.  There’s been work written on how some of the new radicals on the right view any form of compromise as unprincipled when there’s a very strong argument that in the American political system, and in most political systems, enlightened compromise is a great virtue and not a moral defect, but it is not read that way by a certain wing of the Republican party.  So when you have ideological purity of that magnitude on the far right of the Republican party, that is unquestionably a major barrier to getting anything done.

The second thing is that this legislation was pretty bad legislation. I know that can sound very partisan, and if you don’t care about whether people have insurance coverage it’s not bad legislation. It would help a bit over time to reduce the deficit and of course it would give tax breaks to a certain set of more affluent people, but the Republicans really made you think this was going to replace Obamacare, and Obamacare is far from perfect as a policy, but when you begin to look at the Affordable Health Care Act, there are great numbers of people who would be uninsured as indicated by the Congressional Budget Office (CBO) and there are a lot of defects.

A third point that looms large is that this was increasingly unpopular. There was a Quinnipiac Poll that shows that support for this was at 17 percent, opposition was 55 or 56 percent. When members of Congress had town meetings there were protests and people were angry about this. A number of moderate members of Congress said ‘why do we want to get involved with this?’ It was going to increase the number of uninsured appreciably, put great pressures on the states fiscally, and was deeply unpopular.  So the rigidity of the system, the CBO scoring of it as leading to great increases in the number of uninsured, and the negative public opinion were key ingredients to the health care bill’s demise.

What role, if any, do you think race played in the shifting perception and increased popularity of the Affordable Care Act?

There’s no question that some of the opposition to Obamacare had less to do with disagreements about health policy – a lot of the ideas that former President Obama took were actually Republican ideas, originally. A lot of the opposition was about him -- the law’s opponents didn’t like Obama for whatever the reason, some of it was visceral and they didn’t believe he was born here, and even though he said he was a Christian they said he’s really a Muslim, etc. For a certain set of people anything Obama touched was viewed in those terms and it is true that some of the hard right-wing commentators said that minorities are the major beneficiaries. Rush Limbaugh said it was the first step toward reparations, so there was an effort by the opposition to racialize it. But I think now that people have seen the Republican alternative and now that Obama is no longer on the scene as president, I think the racial dimensions of it may well dissipate. They’re getting beyond Obama to seeing it more for what it is and there’s still people like those in the Freedom Caucus who don’t like it, and don’t like government-run programs like this, but still I think that there may be something to that claim. 

Recently, Senator Bernie Sanders said he intends to introduce a “Medicare-for-all” single-payer program and wants to work with President Trump to advance the bill. What is a single-payer program and how does it differ from the current health care model in the United States?

Right now Medicare is this very large program, with more than 50 million enrollees, and it’s for elderly people and some younger people with certain disabilities and specific diseases. The general idea of a single-payer system is that you’d have universal health insurance and it would be like Medicare, which gives you the freedom to pick physicians or in some cases a private contractor. All the money for premiums would flow through the government, and the notion is that the government would cut a good deal because it would have leverage to negotiate with providers, and also do away with a lot of the administrative paperwork. Currently, hospitals have to have huge clerical staffs because there are so many payers – there’s employer’s insurance, there’s individual policies, there’s Medicaid, and there’s Medicare, and so the idea is that there would really be a single payer, which would be the government. Everyone could opt in to this government-run plan, which of course would require some taxation and some payments by enrollees to become members and receive benefits, but it would funnel the money through government.

Do you think that’s feasible for the United States?

Not anytime soon, there are just too many interests that would vigorously fight it. Insurance companies would fight it, I suspect most medial providers would fight it, and people ideologically opposed to too much government would think it’s awful. I just can’t see rapid movement toward that in the current political context.

If Trump really did an extraordinary about-face and became a real populist, maybe you can move along some of that line of thinking if you can get enough Republicans and some Democrats, but I think that would be a really heavy lift. My own hope is that they can patch up the Affordable Care Act, which needs some patching, and maybe extend some benefits beyond it. My guess is that it would be in incremental steps. The other thing would be that if you went to a single-payer system, a lot of people would save money. Employers wouldn’t have to pay for insurance for employees and so on and so forth, but the government would need to come up with a whole lot of money to do that, and it would require very significant new revenues to do that, at least under any such plan I’ve seen which would make it very hard to pull off politically.