As dawn breaks over the wreckage of the GOP’s failed attempt to repeal and replace the Affordable Care Act, one thing is abundantly clear: the Republican Party is not ready to govern. Its chief executive is uninterested in policy details, and far too many of its Congressmembers are too beholden to AM radio platitudes to effectively govern.
First, the President. During the campaign Donald Trump used Obamacare as a punching bag, but was all over the map in terms of what he would replace it with. The whimsical real estate developer was on the record praising Canada’s system of universal government coverage, saying that “it works.” Over the course of the presidential election Trump limited himself to more traditional Republican talking points, but in typical fashion never presented any specifics. But he did make promises that sounded good: universal coverage, no cuts to medicaid, more benefits, lower prices, and just about everything short of a unicorn in every stable. It was clear to anyone who listened that Trump had absolutely no background in healthcare policy or why the subject had bedeviled both parties for decades: as with his business empire, he simply assumed that if he snapped his fingers and told people to make it happen, it simply would. In Trump’s world, the only reason hard things don’t get done is because no one of sufficient power and Nietzschean will gets surly and angry enough to scare the little people into doing them. As with so much else in his first two months in office, President Trump was in for a rude awakening about how the world really works: “nobody knew healthcare could be so complicated,” he said. Not exactly. Everybody knew but him, and he didn’t really care enough to find out.
Which leads us to Speaker Paul Ryan and the GOP Congress. Paul Ryan is often touted as a policy guru, but he’s been unmasked as a dilettante. Seven years after the passage of the Affordable Care Act, Republican lawmakers still didn’t have a coherent plan to replace it. The bill that Ryan and team did come up with essentially maintained the basic structure of the Affordable Care Act, but replaced subsidies with measly tax credits while eliminating requirements that insurers actually cover a wide range of illnesses, and switched out the mandate for an even more onerous tax penalty. The result was a cruel, incoherent plan that didn’t commit to free-market ideology and please hardline conservatives, and was even worse in terms of cost and coverage than plain repeal would have been, thus angering moderate Republicans and ensuring a total blockade from Democrats.
Why did the Republicans not have a plan ready to repeal and replace Obamacare, even though that was their single most cherished policy goal for seven years and the promise that swept them into power in the 2010 and 2014 midterms? Because the core of Obamacare–stricter regulations on private insurers to cover the sick, make feasible via a mandate to purchase private insurance–was always the GOP plan in the first place. As David Frum noted in his excellent autopsy of Trumpcare yesterday, it was the plan hatched by the Heritage Foundation and implemented by 2012 Republican presidential nominee Mitt Romney as Romneycare in Massachusetts. Sure, there were more liberal features tacked onto it, principally the Medicaid expansion. But in terms of covering the uninsured, the young, the sick, those with pre-existing conditions, and those too “rich” for Medicaid but too poor to afford insurance, the structure was the most conservative solution possible: push everyone into private insurance and stick them with a penalty if they don’t buy it.
There are many liberal ways to solve the healthcare problem: universal programs in Canada, the UK, Switzerland, Germany, Japan and elsewhere all have significant differences from one another in terms of funding mechanisms and level of private involvement. But there is only one “conservative” way to do it, and that’s the approach taken by Romneycare and Obamacare. Any other “conservative” solution isn’t a solution at all, but a nonsense, deceptive talking point designed to deceive those who don’t understand public policy. Selling insurance across state lines is a joke. Health savings accounts are an insult to the vast majority of Americans who can’t even save enough money for retirement or a college fund.
But pied piper Republicans couldn’t admit those things to their base–or to their clueless President who didn’t know any better, either. So the mishmash Paul Ryan tried to feed the GOP Congress was a meaner, more incompetent, less ideologically consistent version of the Obamacare they supposedly hated: a tax cut for millionaires disguised as an Obamacare replacement bill.
Not surprisingly, it received withering scorn from nearly all sides. The President kept asking his aides if it was actually a good bill or not. Having failed in his bluff, Trump chose to move on to things he actually does care about, like immigration, infrastructure and trade. The whole healthcare sales pitch wasn’t about the policy–which everyone knew was terrible–but about the political consequences of failing to repeal the Affordable Care Act among the GOP base. Almost no one in the Republican Party was concerned about policy at all, except for the moderates afraid of losing their seats to Democrats in 2018, and the Freedom Caucus whose aversion was based on the rigid ideological extremism of Ayn Rand-worshipping objectivist cultists.
The Republican Party isn’t ready to govern, and it shows.