Missteps, miscalculations and mistakes have almost defined efforts to repeal Obamacare. 

Some political theorists and economists — including conservatives — suggest that one of the biggest mistakes may be the reluctance by Republicans to acknowledge that significant parts of the Affordable Care Act were based on conservative principles.

And that reluctance, they say, kept GOP lawmakers from participating in a process that could have improved the bill and incorporated more of their ideas. It has now left Republicans without a foundation for a viable alternative.

“Voting over and over to repeal, and talk about replacing it, worked very effectively politically, but it put them into a box canyon of their own making,” said Norm Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank.

That’s never been a popular point to make with Republicans. Conservatives said last week that the GOP has changed so much that it is unlikely that the new breed of Republicans would get behind a similar plan if it were to be proposed today, even if were plucked from the diary of Ronald Reagan.

President Trump has continued to push for a repeal and replace bill before Congress leaves for the August recess, an about-face from his tweets last week that said that it was time to, “let Obamacare fail.” And Republican members of Congress have continued to describe the law as a debasement of free market principles.

A Republican template 

Ornstein said that former Sen. Max Baucus, of Montana, and other Senate Democrats who were tasked in 2009 with coming up with the outlines for what would become Obamacare wanted to avoid the backlash that had met Hillary Clinton when she tried — and failed — to tackle the health care system almost two decades before.  So they made a point of starting with a Republican template, working initially with high-powered Senate Republicans Charles E. Grassley of Iowa, Michael B. Enzi of Wyoming and Olympia Snowe of Maine.

The group turned to a plan Republicans had devised as a response to Clinton, according to an account Ornstein wrote in a 2015 article for The Atlantic. 

The plan was built around an individual mandate and exchanges with private insurers. It was derived in part from ideas espoused by the conservative Heritage Foundation — though other scholars had been writing about the concepts for decades.

The individual mandate is a provision of the law that imposes a penalty on people who did not sign up for insurance. Getting healthier Americans, often younger people, to sign up reduced their risk in the event of a catastrophic illness or injury. But at the same time, their participation helped to cover the costs of their unhealthy and older counterparts.

The Supreme Court upheld the constitutionality of the mandate in 2012.

Paul E. Starr, a Princeton sociologist who has written extensively about health care policy, pointed out that more than 20 Republican senators sponsored a health insurance bill with an individual mandate in 1993. Democrats initially opposed the idea and did not include it in the Clinton Health plan that year.

But they were convinced to reconsider, based on the success of Mitt Romney 2006 health care overhaul in the Massachusetts, which was the first to introduce an insurance exchange buttressed by an individual mandate.

Ironically, Starr said in an email, the mandate, turned out to be the most unpopular aspect of the ACA “and of course was totally disavowed by Republicans.”

Starr recently wrote an article advocating for the expansion of Medicaid to people in the 50s, an idea that many Republicans oppose. 

The fact-checking website Politifact twice looked into claims about the conservative origins of the bill. In 2010, when Obama touted the Romneycare and Heritage foundation connections as a talking point for his bill, Politifact determined that the claim was mostly true. Three years later, it looked into claims that Obama’s bill was the same as the Senate proposal from the 90s. That claim, it found, was “half-true,” because the proposal never came to a vote and many conservatives didn’t like it.

The Heritage Foundation has pushed back against this narrative.

“Heritage in no way supported or encouraged the individual mandate that is part of the Patient Protection and Affordable Care Act,” said spokeswoman Marguerite Bowling. She said that policy analysts were talking about the idea of an individual mandate years before the foundation published a paper on the topic in 1989.  The Heritage Foundation believes the mandate in the Affordable Care Act is unconstitutional and the whole law should be repealed, she said.

Stuart Butler, the scholar who originally wrote about the idea of the mandate for the Heritage Foundation, has also taken issue with the idea that the Affordable Care Act originated, in part, with his ideas. He said that what he proposed was much less sweeping.

He said his version of a mandate would have only encouraged — not required — people to get basic, catastrophic coverage, not the complete plans offered under the Affordable Care Act. 

Butler has since concluded that even that is not the best way to get people to sign up for coverage. Other pieces of the Affordable Care Act, particularly the expansion of Medicaid to help defray costs on the private market, “have nothing in common,” with conservative theories, he said.

He nevertheless agreed with the idea that some of the features of Obamacare had “bipartisan paternity.”

“The failure to really find a compromise in 1993, 1994, when there really was a lot of common ground, was a historical tragedy because we really could have solved a lot of these problems at that point,” he said. “But politics got in the way.”

A tougher challenge

Trying to reopen the debate today will be much harder, Butler and other political observers said.

Indeed, Republicans in the current Congress have stuck to now familiar talking points, describing Obamacare as a socialized system that has threatened to destroy the insurance market. 

Last week, Utah Sen. Orrin G. Hatch described, “mandates and taxes that have collectively weakened or wreaked havoc on our health care system.” And Rep. Louie Gohmert, R-Texas, said failing to repeal the law would result in, “more and more rationed care.”

“Obamacare restricts choice. It denies competition,” House Speaker Paul Ryan said in March. 

For lawmakers today, nuances of the past aren’t driving the debate.  

“I don’t think anyone is reflecting back on that, or frankly that it makes much of a difference to this current group,” said Sheila P. Burke, who worked on some early iterations of health care reform as Sen. Bob Dole’s chief of staff in the 70s and 80s. “I don’t think they care whether it came from Richard Nixon or Ronald Reagan.”

Burke, now a strategic advisor for the Baker Donelson law firm and lobbying group, said the Republicans who have been the among the most vehement opponents of the Affordable Care Act — including Sens. Rand Paul, Mike Lee and Ted Cruz — are more concerned with shrinking or eliminating entitlements, such as Medicaid, than devising a plan for the federal government to define what insurance should cover or creating incentives for people to buy it. 

Many of the moderate members who would have been open to a compromise during previous iterations of the debate have left. Those who remain — such as  Grassley and Hatch — have hardened their positions.

Daniel McCarthy, editor-at-large of the American Conservative magazine, said some of the ideas in the Affordable Care Act became tainted in conservatives’ minds as soon they became associated with President Obama.

As conservatives looked more closely at the plan, they realized they didn’t like certain features, such as the Medicaid expansion and the subsides necessary to keep it afloat, he said. Those objections have since solidified. In the meantime, changes in the GOP have made it much harder for Republicans to unite around an alternative.

But, he said, the collapse of repeal and replace could create an opening for more pragmatic Republicans to negotiate piecemeal reforms based on the free market principles that Obamacare attempted to embrace.

“Now the question becomes, does it become politically depolarized if some sort of modified, but still basically kind of similar arrangement is produced by the Republican majority?” he said. “Or does it remain something the conservative grassroots don’t like because they say, ‘Wait a minute, this is something we don’t like because it originated with Barack Obama.’”

All of this, McCarthy and others said, will depend on what happens in the 2018 midterms. If the Republicans increase their majority in the Senate, they could potentially return to repeal and replace.