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The latest chapter in the ongoing story of Republican efforts to repeal the U.S. Affordable Care Act came to an end quietly this week. Senate leaders and the bill’s sponsors pulled the legislation from consideration when it became clear they did not have the votes needed to pass the Graham-Cassidy bill, which would have repealed the ACA.
Just the day before the GOP bill died a quiet death, the scene was more boisterous. The bill sponsors, Sen. Lindsey Graham, a Republican from South Carolina, and Sen. Bill Cassidy, a Republican from Louisiana, sparred with Sen. Bernie Sanders, an Independent from Vermont, and Amy Klobuchar, a member of the Democratic-Farmer-Labor Party from Minnesota, in a live cable news channel debate on the future of health care.
Republican leaders on Capitol Hill rushed to marshal the votes to pass the bill, as U.S. Capitol Police arrested and removed noisy demonstrators protesting the proposed legislation that they feared would leave more Americans without health insurance.
To provide insight into the continuing battle over health care reform, the 17th annual Marshall J. Seidman Lecture at Harvard Medical School, held on Sept. 25, featured two leading health care policy researchers who have served senior officials and advisors to Republican and Democratic administrations.
"Health care has always been a hot-button issue,” said Barbara McNeil, the Ridley Watts Professor of Health Care Policy and head of the Department of Health Care Policy at HMS, in her welcoming remarks, “but today it's the hottest button."
McNeil added that she couldn’t think of anyone better than this year’s Seidman lecturers to put that heat into context.
Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute, opened the discussion with an analysis of Graham-Cassidy, which he said was based on the premise that the federal government should remove itself from difficult policy choices concerning health coverage and leave those to the states.
Antos said after years of working to oppose President Barack Obama, the Republican-controlled U.S. Congress was taken by surprise when Donald Trump was elected President last November.
“They didn't expect to have a Republican in the White House,” Antos said. “They weren't ready.”
For years, Antos said, mainstream Republican health care reform proposals were built on many of the same principals embodied in the ACA and included increasing access to care, helping people with low incomes purchase insurance on the individual market and promoting consumer choice.
On the other hand, he said, the legislation proposed since the election has focused more on shifting control of insurance from the federal government to states and families and, crucially, on providing a legislative win that would allow Republicans to say they had repealed Obamacare.
The challenge for Republicans, Antos said, was how to get moderate Republicans to work together with the right wing of the party. Any attempts to placate the centrists—who wanted to preserve some protections for patients and consumers that were afforded by the ACA—risked driving away deficit hawks and small government advocates who want to prioritize spending cuts and minimize the role of federal government in health care.
“This is a fissure that everyone has known was there all along,” Antos said.
On the other side of the aisle, the Democrats would like Republicans to admit that the ACA did some good, said Len Nichols, professor of health policy and director of the Center for Health Policy Research and Ethics at George Mason University and former principal research associate at the Urban Institute.
Nichols noted that the ACA extended health coverage to 20 million people who wouldn't have had it otherwise and that it has focused attention on the need to control spending growth and given providers incentives to focus more on population health and on fixing the underlying social inequities that can promote ill health. Democrats want to build on those successes to cover more Americans and improve the overall health of the population, Nichols said.
“The Democrats also want Republicans to work with them to fix what's wrong with the ACA, and to give every American a chance to be healthy, to live up to their full potential and to make America greater together,” Nichols said.
Going forward, Antos and Nichols agreed that there are provisions within the ACA that may help both parties further their goals.
For example, they noted that strengthening the provisions of Section 1332 of the ACA would give state governments opportunities to experiment with different methods of care delivery that could be tailored to meet the political, cultural and health needs of local communities. This would have the advantage of devolving decision making to states and local communities while maintaining protections for people with preexisting conditions and guaranteeing minimum standards for coverage built into the law, while also allowing for innovation and creative solutions to the challenges of providing care for the diverse population of the nation.
In 2000, on the occasion of the 50th reunion of his Harvard Law School class, Marshall J. Seidman provided endowment support to the Harvard Medical School Department of Health Care Policy to support research related to health care costs and quality and to host an annual meeting by a leading policymaker on issues related to costs and quality of health care with a particular emphasis on activities that are most likely to impact federal and state approaches to these problems. The department has sponsored the lectures yearly since 2001. In 2004, the HMS Department of Health Care Policy established the Marshall J. Seidman Program for Medical Economics, which supports cost and quality research through the Seidman Fellowship Program.
