Despite the desirability of policy modesty, therefore, Republicans may need to be politically bold to break the deadlock. That means they should consider a game-changer that would have been wiser to try from Day One: a straight up-or-down vote on repealing Obamacare first, putting it on a path to expire at the end of 2018 with or without a replacement. Doing so would put Republicans who have voted repeatedly for repeal in past years to a test of their sincerity. It would radically alter the incentives of all the political actors in the system. It would dramatically reduce procedural and, potentially, litigation risks. And it would create the space to forge new, potentially bipartisan agreements on individual, more modest elements of the health-insurance system instead of insisting on a single party-line “comprehensive” system. The result might not be a system that conservatives love, but it would stand a better chance of enactment and positive policy progress in the short term and greater long-term stability for the system.
Republicans’ immediate problem right now seems to be intra-GOP division on a comprehensive bill. But that diagnosis carries two implicit assumptions: that health-care legislation can never be bipartisan, and that a replacement needs to be a comprehensive program. But it’s procedurally impossible, under current conditions, to do both — in fact, even the AHCA was supposed to be passed in two stages (plus a third stage of new executive regulations), precisely because the parts of the bill that need 60 votes in the Senate (and therefore need Democratic support) have to be separated from the parts that need only 51 — and Speaker Paul Ryan never had an apparent strategy to get those votes.
By contrast, a repeal-first strategy would change the game and might even let Congress break the partisan gridlock on health care. The Byrd Rule means that Democrats have the power, if they stand united, to make it impossible to pass a single, comprehensive Republican health-care proposal. But it doesn’t give the Democrats the power to prevent Republicans from repealing and defunding so much of Obamacare that it is no longer a viable option. If Republicans do that, they can bring a significant number of Democrats to the table. Once the current system has been scrapped, nobody who wants the government to pay for health care or regulate health insurance could afford to stay on the sidelines. By burning the ships behind them, Ryan, Trump, and Mitch McConnell could — paradoxically — create more incentives for bipartisan de-escalation and compromise.
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