Theories of Congress and the Rocky Road Ahead for Repeal-and-Replace

The House is currently debating healthcare reform and I think that it’s worth revisiting the current legislative process from a political science view.  The real fight has not yet been joined – there’s relatively little hope for liberal activists to stop the bill in the House, where intra-conservative discord is the main potential stumbling block.  The action will happen in the Senate, and there are a few different theories from political science that shed light on the difficult path ahead for the Republicans.

  • Home-state concerns drive votes:
    • The framework: Senators vote on parochial concerns for their state.
    • The takeaway: In this light, the bill is in serious trouble.  There are a wide variety of GOP Senators whose home states have benefited a great deal from Obamacare, ranging from Senator Cotton (AR) to Paul (KY).   There’s a diverse coalition of groups that will oppose the bill, and opposition will intensify as various stakeholders (hospitals, etc) lean on Senators.
    • The path forward: It is difficult to see a way around the sticking point – the Medicaid expansion.  Repealing the Medicaid expansion drives opposition from both moderate and conservative senators, but without the Medicaid expansion repeal the cost of the bill balloons, ruining Speaker Ryan’s plan to pass permanent tax cuts through reconciliation.
  • Politics is unidimensional and ideological: 
    • The framework: Senators vote on a left-right spectrum..
    • The takeaway: In this light, the bill is virtually doomed – the GOP Senate Caucus has actually moved leftwards since 2012, contrary to popular wisdom.  The pivotal Senator here is probably Dean Heller, already an avowed opponent of Medicaid expansion repeal, and there are indications it could be difficult to round up even 45 Republicans to vote for Medicaid expansion repeal.
    • The path forward: Replace-and-replace is DOA. Again, repealing Medicaid expansion is the blocking issue – it’s a fairly far-right position and may even be to the right of the pivot point in the House, depending on whether the GOP moves up the deadline to 2018 as has been discussed.
  • Politics is multidimensional and ideological:
    • The framework: Senators vote on a left-right economic spectrum and a second axis that seems to encompass social issues (e.g. abortion).
    • The takeaway: The bill isn’t dead!  A relatively right-wing healthcare bill can be moderated in the second dimension in order to move it into acceptable range for passage, potentially by, say, removing provisions that defund Planned Parenthood.
    • The path forward: Unfortunately for the GOP there’s probably limited room to do these sorts of issues through the reconciliation process – however, a leadership could potentially throw other bones to moderate members in follow-up bills.   The difficulty here is twofold – one is a time-consistency issue, where moderates would have to trust leadership to follow up, and the other is that anything else leadership promises would have to pass through regular order and is subject to a filibuster. Also, incidentally, the second dimension of politics appears to be collapsing in Congress so this may be moot.

In short – most schools of analysis suggest that repeal-and-replace is in trouble. The legislative strategy GOP leaders have chosen is extremely difficult, especially as the rest of their agenda depends on a quick passage of this repeal-and-replace bill.  If I were a Republican, I would be concerned that Speaker Ryan does not appear to have considered the complexity of this endeavor – if timely passage is a necessity, he should have come to the table with a bill that was mutually acceptable to pivotal members in both the House and Senate.  This oversight does not bode well for the rest of their ambitious legislative agenda.

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