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Viewpoint: The health care mess explained

By Eric Burin

A little over two weeks ago, on a Thursday night in late July, Senate Republicans staged one of the most bizarre political events in modern American history. After having failed to pass two much-maligned healthcare bills, GOP leaders unveiled a third bill and scheduled a vote on it just a few hours later, sometime after midnight.

Like the first two Senate bills, this third bill, popularly known as the "skinny repeal," was crafted in secret and almost universally decried. The bill was so disdained, even its supporters in the Senate demanded that the House vow to not concur with it, lest the "skinny repeal" actually become law. Despite the absurdity of it all, they came within one vote of passing the measure.

Republicans control the House, Senate, and presidency, so why have they struggled to pass a healthcare bill — especially since they've been promising something better than the Affordable Care Act (commonly known as Obamacare) for over seven years?

For starters, they don't have a clear vision for what should replace Obamacare. Obamacare is essentially a conservative system; it's modeled on the plan implemented by Republican Mitt Romney when he was governor of Massachusetts.

Republicans are trying to undo a system they once championed, and they don't agree about what should take its place. As a result, some Senate proposals could hardly be called healthcare legislation. For example, the first bill's most distinguishing feature was a massive tax break for the wealthy, which would be offset by cutting over $770 million from Medicaid. Senate Majority Leader Mitch McConnell's decision to keep nearly everybody in the dark on such measures was unseemly, but, tactically, it made sense. He knew they could never stand public scrutiny. In the end, although North Dakota's Republican Sen. John Hoeven voted for the first two bills, they failed nonetheless.

Undaunted, Republicans forged ahead. Pride, obstinacy, and the fear of a primary challenge made them feel that they had to repeal Obamacare, even if doing so would make things worse. Good governance and effective policies be damned, they were going to pass something. This mindset, when combined with the absence of viable policy alternatives, led to that surreal scene in the Senate over the fate of the highly unpopular "skinny repeal."

Hoeven is immensely wealthy and popular, and he won't face re-election for over five years, so he was well-positioned to say to his Republican colleagues, "This is nuts. We can do better." Instead, he watched as GOP moderates Susan Collins and Lisa Murkowski, despite threats of violence against themselves and economic retaliation against their states, broke ranks and opposed the "skinny repeal," and as John McCain sealed the measure's defeat with an emphatic thumbs down.

In the aftermath of the bill's demise, President Trump, whose erratic behavior during the healthcare saga had done his party no favors, threatened to sabotage certain health insurance markets, essentially holding the Americans who use them hostage as a means reviving the healthcare debate. Consequently, some Republicans are talking about giving it another shot, believing that they can produce a bill that would get 50 votes — as if 50 votes was an end unto itself, as opposed to, say, improving the healthcare system.

Others are pushing back. The bipartisan National Governors Association, for example, decried the president's arm-twisting and the harmful uncertainty it's causing in the healthcare markets, while here in North Dakota, the Republican Insurance Commissioner called Trump's threat "an unfortunate leverage piece" and warned that premiums would rise if the president followed through, a prediction echoed by insurance providers in the state.

The "skinny repeal's" defeat also sparked soul-searching among some GOP lawmakers. Orrin Hatch of Utah remarked that the Senate was simply too divided to take up healthcare immediately. Arizona's Jeff Flake published a thoughtful reflection on the dangers of prioritizing political wins at the expense of long-held principles, while his counterpart McCain likewise insisted that the Senate "must now return to the correct way of legislating." Murkowski and a few other moderate Republicans went even further, and began dialoguing with Democrats in a bipartisan effort to improve the healthcare system. Perhaps this was all just political theater, but, at this point, any constructive effort is a welcomed step in the right direction.

And then there was Hoeven, who penned an op-ed that simply recycled the same tired GOP talking points. In doing so, Hoeven, unlike Flake, McCain, Murkowski, and others, showed that he hasn't changed one bit. Hoeven's most rigid supporters may applaud his intractability, but everyone else can lament that he is ready to go down the rabbit hole again—the same hole that led to that sorry moment in late July, when in the dead of the night the Senate clerk called his name regarding a bill that had just been released and no one really wanted to become law, and he answered "yea."

Eric Burin is a history professor at UND, specializing in American political history.

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