The Health Care Albatross

Republicans should get used to it. Their agony on health care is just beginning.

For the past seven years, the party benefited from its powerlessness, which usefully maximized its ability to criticize Obamacare and minimized its responsibility to do anything about it. Now, with unified control of government, the party will pay the piper.

Nothing good will come of the Obamacare repeal-and-replace debate. If anything resembling the current bill passes and is signed into law, Republicans will spend years trying to fix it. If the bill fails, the rest of President Donald Trump's legislative agenda may sink with it.

The party faces this choice between Scylla and Charybdis because the House leadership couldn't produce a sound repeal-and-replacement bill that it thought would pass muster with the Senate parliamentarian. Instead, it unveiled a compromise of a compromise, jury-rigged to pass the Senate under the so-called reconciliation rules bypassing the filibuster.

The reflex of the Republican leadership was understandably to pass the awkward bill quickly and move on. But the lesson of Obamacare is that passage of a major health care law never puts health care behind you, only in front of you. For Republicans, their replacement bill will -- one way or the other, pass or fail -- loom large in 2018 and presumably 2020, if not beyond.

A fundamental flaw of the Republican bill is that it will likely destabilize the already rocky individual market even further. The legislation leaves in place the core Obamacare regulations that are driving up the price of insurance, while repealing the individual mandate that is designed to force people to buy insurance anyway. Almost no one who is not directly employed by the Republican Party thinks this combination makes sense.

Then there is the fact that fewer people will have insurance. The Congressional Budget Office projection of 24 million fewer in 10 years is probably too dire, but there is little doubt that the number is substantial.

None of this makes for a sustainable law. Republicans admit as much with their talk of a "three-prong" approach, an implicit concession of the inadequacy of Prong No. 1. If they pass their bill, Health and Human Services Secretary Tom Price will supposedly swoop in to deregulate and stabilize the individual market through administrative action, and then Congress will pass additional free-market reforms with 60 votes in the Senate. Because it's not clear what exactly Price can do, the second prong is a black box. And because 60 votes obviously means getting Democratic support, the third prong is a fantasy.

This fix-it-on-the-fly approach should sound familiar because it's exactly the tack the Obama administration took on Obamacare. It's just one of the discomfiting echoes of the health care debate from 2009-10. After Republicans accused the Democratic Congress of jamming through an Obamacare bill in eight months, they have been trying to pass their own hugely consequential bill in four weeks.

If the Republican leadership hasn't covered itself in glory, neither has the rank and file. The conservative Freedom Caucus says it wants a "full repeal" and laments that the party isn't simply passing the repeal-only it sent to President Barack Obama's desk in 2016. But that bill also left core Obamacare regulations in place. What many of these conservatives really mean when they say they want "full repeal" is that they don't want a replacement, which is even less defensible than what the leadership has been trying to do.

The fact is that the party is deeply conflicted on a promise it has made to voters for years, and it shows in the patchwork House bill. Paul Ryan is the wonk, and Donald Trump is the populist, and neither did his job in formulating and pushing an incoherent bill that will lead to fewer people having insurance.

Even if they manage to pull off the major political win of getting their bill through Congress, they won't be done with it -- no, not for a very long time.