By: Robert Heilberg

The highly publicized debacle that ended in the failure of the American Health Care Act (AHCA) at the hands of divided factions of congressional Republicans exposed not only in house divisions within the GOP, but a frustrating failure within the party to sell the merits of their legislative agenda.

The ACA is fully intact, and as a result of the newly agreed to omnibus spending bill to fund the government through the end of September, Obamacare subsidies remain fully funded (for now) even as a second repeal and replace bill heads to the floor of the house. The new bill has received an endorsement from the conservative House Freedom Caucus (a key player in killing the first bill) after a key provision to strip protections for patients with pre-existing conditions, which in theory will help to bring down premiums across the board was included in the new legislation. As Republicans prepare to hold a vote on the revised legislation, they may very well have the numbers to pass it this time. But is this truly the Obamacare alternative Republicans envisioned, and do they understand the consequences of losing the public opinion game, even if they aren’t necessarily wrong about the sentiment behind repealing the ACA. Even if this legislation does pass the House, which looks very likely, it is also likely the legislation is dead on arrival in the Senate. Bringing the revised health care bill to the floor without a report on its impact from the Congressional Budget Office (CBO) makes this entire process reek of the way Democrats passed Obamacare a few years ago on a party line vote. The famous line uttered by then Speaker Nancy Pelosi that, “we have to pass the bill so that you can find out what is in it,” was rightfully decried by Republicans. It was a line reminiscent of everything that is wrong with establishment politics, and it forced the American people to accept a landmark healthcare resolution where they were unfamiliar with the effect it would have on them and their families. What is happening right now is no different, and if the law is truly dead on arrival in the Senate, repeal and replace will only become more difficult with less political capital and an impatient public during round three.

The ACA was never a law intentioned towards bringing down the cost of care. The goal of the ACA was to cover as many people as possible under a state based expansion of Medicaid regardless of the effect on costs and accessibility. The nonpartisan Kaiser family foundation analyzed the effect of the ACA on the statewide healthcare market, and found that nearly one-third of counties in America are down to one provider on the exchange market as of this year. This statistic is troubling given that in the previous year, the number of counties with only one provider was just 7%. Alabama, Alaska, Oklahoma, South Carolina and Wyoming are now down to one online market provider as entire states. Additionally the average premium increase for the current fiscal year across all states according to the Department of Health and Human Services (HHS) is 25%, with many states seeing their premiums double. Republicans have identified the problem but not the solution. Democrats have identified neither. They have clung to a recent surge in support for the ACA in public opinion polls mainly attached to vehement opposition to the Trump administration on the left, not a substantial change in the law’s success. In fact the ACA is on a downward spiral, not on the rise, which makes it easy to explain recent spikes in public opinion in favor of the ACA as a reaction to the Trump administration, not support towards the law itself. The approach of the Democratic party is to rally support for the bill while not addressing the real concerns of Americans struggling under the structure of the ACA. The problem with Republicans on the other side is even when they have a bill, they are more concerned with selling it to their members and not the public at large. It is the definition of poor public relations in the arena of public policy, and it has hurt the GOP’s image as a governing party and their leverage on Capitol Hill. More simply put, it is difficult to sell landmark reforms to health care to the public when you are more concerned with getting your members on board and are therefore forced to abandon the broader sales pitch.

The new developments about rising premiums and insurers fleeing the market place at alarming rates highlight the troubling trajectory of Obamacare, and whether or not the law can be salvaged is up for debate. What is not up for debate is that the GOP, now the governing party, has an obligation to repeal the law and replace it with an alternative that addresses concerns about market options and premium prices, or simply make a bipartisan attempt to revamp the ACA if that is possible at this juncture. What Republicans should be focused on is a bill that is centered around cost control and expanding access to medicine that is affordable and insurance that is both portable and can be purchased across state lines. But if lowering costs comes solely at the expense of the care of sick people, the image and public relations problem hovering over the GOP replacement will only continue to linger. Additionally, the question of how to make much needed prescription and over the counter drugs more affordable will become an issue that GOP lawmakers will need to address, and perhaps seek bipartisan support for. If turning to alternative markets to deal with the rising costs of pharmaceuticals becomes the only viable free market cost control solution for necessary medications, a GOP bill in the future may need to address altering the market place.

The federal government has given unprecedented protections to American pharmaceutical companies which protect them from having to compete with Canadian and European drug manufacturers who make life saving and altering drugs at a much cheaper cost. Lifting this monopoly will flood the market with cheap alternatives and present an ultimatum to American pharmaceutical companies. Make your product more affordable, or lose out on the free market to those who can do it cheaper. This will involve slashing regulations and restrictions imposed by the Food and Drug Administration (FDA) on the importation of these drugs, even though safety should remain a priority. It is antithetical to the Trump administration’s stance on buying American to turn to foreign markets for a solution, but this reform is a necessary component of a long term cost centered health care overhaul, and it has bipartisan support from lawmakers such as Bernie Sanders and Ted Cruz in the senate.

A major problem for Republicans is they do not have the votes in the senate required to reach the sixty vote threshold for a full repeal, and therefore have crafted a reconciliation bill, which deals with going through the budgetary process to overhaul the ACA. Reconciliation legislation limits what GOP lawmakers can do in replacing the ACA because every change needs to go through the budgetary process, and the bill as a whole needs to remain deficit neutral (not increasing the deficit, which is why a CBO report is important). If this bill falls short of significantly slashing premiums across the board and creating a vibrant free market to purchase affordable health care, the only result of this legislation if successful will be the defeat of congressional Republicans during the midterm elections at the hands of an energized Democratic base and a demoralized conservative base due to the failure to make good on governing promises. Paul Ryan’s inability to grapple with the challenges that would come with overhauling the ACA and transitioning to a so called governing party instead of a mere opposition party highlights the disconnect between campaign rhetoric and actually governing. Paul Ryan took heat for struggling to draft a replacement plan in the first place (before the election), and when he finally did, it appeared rushed and the process culminated in the failure of the first bill to even get a vote. Although in fairness to the Speaker, presenting the AHCA to the public before the election likely would have energized Democrats with a strong message of opposition.

The only viable health care alternative will require unifying all factions of Republicans, moderates, conservatives, and libertarians in the House and the Senate. But it will also require making a case to the American people of why their plan is better than the ACA especially during a time when Democrats have so effectively rallied together faux support for the law really just rooted in anti-Trump opposition. If the law is allowed to implode, it will be at the expense of all Americans, and both parties will be to blame. Mass coverage regardless of cost and access should not be the priority. The priority under any truly conservative bill needs to be centered around the patient in a way neither of the first two bills have been. The number of people covered won’t be the measure of success in any new healthcare legislation. The impact on the overall market and accessibility will be. But Republican leadership will need to understand the American people, more concerned about access to health care than ever, need to be sold on the merits of repeal and replace. Messaging and salesmanship has never been more important, but selling a bill will be hard if the final product is a poor alternative.