Why Obamacare survived

On Tuesday, Graham-Cassidy, the final Republican replacement for Obamacare, died. “We don’t have the votes,” said Sen. Bill Cassidy (R-LA), a co-author of the bill. With that, the clock on budget reconciliation — the special legislative vehicle that allows Senate Republicans to pass a bill protected from the filibuster — will expire for this year.

That doesn’t mean the Obamacare repeal effort is dead forever. As Vox’s Sarah Kliff writes, it won’t truly die so long as Republicans control Congress. The GOP could try again next year, or the year after. But the path gets harder from here. The midterm election gets closer. A new bill would have to clear the House all over again, as well as the Senate. And Republicans still haven’t solved their central problem on health care: They don’t have an idea that they, or the public, actually like.

On Twitter, congressional reporter Steven Dennis noted that Obamacare has had far more than its allotted nine lives. It’s survived the unexpected election of Sen. Scott Brown, two Supreme Court challenges, the 2012 election, Sen. Ted Cruz’s government shutdown, the Healthcare.gov debacle, the House’s American Health Care Act alternative, the Senate’s Better Care Reconciliation Act alternative, the “skinny repeal” effort, and Graham-Cassidy.

The secret to Obamacare’s persistence is that the American people want the health care system made better — by which they mean they want more people to have affordable health insurance — and Obamacare achieves that goal. By contrast, the GOP, at every single turn, has offered plans to make the system worse.

The Supreme Court challenges would, if successful, have sent premiums skyrocketing across the country. (As it is, the Court’s decision to let states opt out of the Medicaid expansion deprived millions of poor Americans of comprehensive coverage.) The 2012 election pitted Barack Obama, a candidate with a plan to cover more people with health insurance, against Mitt Romney, a candidate with a vague plan to cover fewer. Cruz’s shutdown gutted government services with no endgame save for giving fewer people the means with which to buy health insurance. And every single Republican replacement bill that was scored would’ve led to tens of millions fewer people with insurance and particular pain for the sick, the poor, and the old — the exact groups that need help most.

Republicans know their health care ideas are unpopular. That’s why they obscure them. They campaign promising universal coverage and lower deductibles and no cuts to Medicaid and care everyone can afford. They run rushed legislative processes devoid of hearings and debate, and when they can, they fight to take votes before the Congressional Budget Office can tell the public what their proposals actually do. Faced with the problem that they are offering less coverage and worse insurance to a country that wants more coverage and better insurance, they have chosen deception and speed rather than rethinking their ideas to better match public preferences.

If Obamacare were truly the disaster Republicans say it is, this would, perhaps, have worked. But the reality is that for most people, in most places, the Affordable Care Act is working. The bulk of its coverage expansion has been through Medicaid, which is immune to the problems of the insurance marketplaces. Surveys find that Medicaid enrollees really like their coverage; they’re just as satisfied as people who get health insurance at work. Indeed, the Medicaid expansion has proven so popular, and so effective, that Republican governors from Medicaid-expanding states like Ohio and Nevada have been fighting to preserve it.

Nor are the exchanges in anything close to a state of collapse. More than 10 million people are buying insurance off Obamacare’s exchanges, and surveys show most of them are happy with their plans.

Nor has the Affordable Care Act seen exploding costs either in the program or in the health care system more broadly. The ACA has cost less than the Congressional Budget Office expected, and spending growth in the health system overall has been at historic lows (an achievement for which Obamacare deserves some, though not all, of the credit). Cost control in the health system has been so unexpectedly effective that the government is now projected to spend less on health care with Obamacare than we were projected to spend without Obamacare.

Obamacare’s biggest problem is the high cost sharing that frustrates those who buy coverage on the marketplaces. But all of the Republican bills would lead to higher deductibles, higher copays, sparer insurance, and, on an apples-to-apples basis, higher premiums.

This is the reality that Republicans are flinging their repeal effort against — and it is a reality that their plans mostly worsen. Though Republicans routinely deride Obamacare as a catastrophic failure, it is nevertheless setting a benchmark none of their plans can clear. Republicans have spent years complaining that the Affordable Care Act covers too few people with insurance that costs too much and covers too little. But they have only managed to produce alternatives that underperform it. In lieu of passing any of those alternatives, their current plan is to publicly sabotage Obamacare — once again, a strategy where the policy result is higher premiums and less coverage, exactly what the public doesn’t want.

Could the American health care system be better than it is today? Of course. But it could also be much worse. And so far, much worse is what Republicans have offered.