As Republicans focus on whom to blame for the collapse of Trumpcare, they have ignored the most important culprit: self-deception.
For seven years, they have run a campaign against Obamacare that was full of exaggeration and distortions. Over time, they and their voters came to believe all sorts of things that weren’t true—and those false assumptions ended up crippling their ability to repeal and replace Obamacare.
Let’s go through them:
Obamacare was one of the worst things ever to happen. As soon as Barack Obama proposed the Affordable Care Act, we saw an arms race of hyperbole. It was insufficient to oppose it; one had to do so in a truly memorable way. So we ended up with comments like:
“Obamacare is really I think the worst thing that has happened in this nation since slavery.” (Ben Carson)
“If this passes and it’s five years from now and all that stuff gets implemented—I am leaving the country.” (Rush Limbaugh)
“This is the end of prosperity in America forever.” (Glenn Beck)
“[Obamacare] will bankrupt our nation, and it will ruin our economy.” (John Boehner)
“Obamacare designed to replace middle class with low-income renters.” (Alex Jones)
These sentiments have bombarded conservative voters for roughly 2,500 straight days. In this context, the stubbornly negative reaction from the Freedom Caucus was totally logical and predictable. When a law is worse than slavery, you really ought to just repeal it. The fact that Paul Ryan accepted a lot of the structure of the ACA made it even worse.
The Freedom Caucus rebellion wasn’t caused by disloyalty or disunity; it was caused by seven years of hyperbolic rhetoric.
Premiums are skyrocketing because of Obamacare and so a Republican plan would lower premiums. Republicans walked into a trap of their own setting: if Obamacare was what was causing premiums to rise, then their plans can and should make premiums go down. Or as Donald Trump put it: Rates will “go down, down, down.”
Going into the Trumpcare fight, that became the new standard. Almost all of the members of Congress who opposed the AHCA said that one of the reasons was it wouldn’t lower premiums.
The idea that Obamacare was causing premiums to rise was never quite right, or at least was overstated. Rates in the individual market were rising rapidly but rates for employer-based plans, where most people get their insurance, were increasing more slowly. But having established this as the new test of policymaking success—will it raise or lower premiums?—the Republicans found themselves in an untenable position.
What started as an unreasonable criticism of the ACA became an unreasonable expectation for AHCA.
The voters hated Obamacare because it got government too involved in health care. For years, Republican pols pointed to polls showing Obamacare was unpopular. For instance, a CNN/ ORC poll in 2013 showed that 53% opposed it and 43% supported. How hard could it be to repeal a massively unpopular law?
But conservatives usually misinterpreted the polls. That CNN poll also said that while 35 percent opposed the ACA for being too liberal, 16 percent opposed it for being not liberal enough. So the percentage favoring an ACA-level of government intervention or more was 59 percent. This pattern persisted for the past seven years. The actual coalition for repeal has always been in the 35 percent to 40 percent range.
It shouldn’t have been a huge surprise that during the fight over Trumpcare, many voters turned out to oppose the AHCA or support Obamacare – including, most significantly, those in the districts of moderate Republicans.
Health care is expensive because consumers don’t bear enough cost. The underlying theory behind the conservative approach has been that because consumers are insulated from the cost of health care, they make bad health care choices.
Unfortunately, that meant their entire policy was based on a premise that they couldn’t really say out loud – that people should pay more for health care. On the rare occasion that they tried—like when Jason Chaffetz suggested that people could solve their health care woes by delaying a purchase of an iPhone—they sounded clueless. Donald Trump massively exacerbated the problem by flat out saying that Americans should have lower deductibles and pay less for health care. This is one of the reasons the conflict between Freedom Caucus members and moderates was so intractable: one group thought that having families pay more was the solution; the other group thought that was the problem.
This premise also misunderstands health care economics. As Shannon Brownlee explained in the Washington Monthly, the real cause of health care cost inflation is something quite different:
“The vast majority of Americans aren’t big users of the health care system. Rather, statistics show that 5 percent of the population accounts for fully 50 percent of all health care spending, and 20 percent of individuals consume fully 80 percent.
Who are these people? They are our elderly parents, whose health is slowly deteriorating and who need help coping with their worsening illnesses. They are younger people, most of them still working, who suffer from multiple chronic conditions, such as diabetes, lung disease, and rheumatoid arthritis. Many of these patients have mental health problems that make it a challenge for them and their doctors and families to deal with their chronic physical ailments. These are people who, almost by definition, can’t use their purchasing power to fix an out-of-control health care market, because they rapidly spend down their deductibles on necessary care, leaving the bulk of the cost to be paid by insurance. These folks have plenty of skin in the game—their own skin.”
By misunderstanding health care economics, the Repulicans have opted for solutions that don’t solve actual problems. Neither the Congressional Budget Office (or any other health care analyst) will ever conclude that only doing deregulation and more generous health care savings accounts will sufficiently curb health care costs.
More important, the more that voters understand that this is the theory behind the Republican approach, the less they are like to approve.
Coverage gains under Obamacare came mostly from the mandate. Conservatives have argued, and no doubt came to believe, that the ACA mostly lowered the rate of uninsureds by forcing people to pay for coverage they didn’t want. But it turns out lots of people got insurance because they wanted it! Because conservatives misrepresented the reason for coverage growth, they no doubt figured that dropping some people from the rolls wouldn’t cause too much voter angst. Perhaps strategists became less attentive to the political downsides of a plan that caused 24 million people to lose their insurance.
We also can’t forget what a big deal it was that the AARP and the American Medical Association both came out against the Republican plan. They both cited the loss in coverage as a major reason for their opposition.
Obamacare is socialism. It was called a socialist government takeover. Obama pointed out that the idea of having a marketplace for private individual insurance plans, came from Mitt Romney and the Heritage Foundation. But conservative politicians either didn’t believe the claim or chose to ignore it.
In the short run that denial worked fine, but when Republicans tried to offer a market-oriented replacement this year they found themselves in a pickle: they had discredited their own best idea!
So when Ryan went back to the original conservative approach—he preserved the exchanges and a system of individual subsidies—conservatives objected. After years of saying the approach was socialism, it was a bit too late to say, à la Emily Litella, “never mind” and return to their pre-2009 position.
Democrats jammed through a partisan plan without attempting to gain Republican support. Republicans may have come to believe that Obamacare got through because it happened fast. If they wanted to win, they had to do it quickly, too.
Misconceptions about the politics of the 2009 reform may have blinded them to some political opportunities. So intent were they on claiming that Obama was partisan, conservatives blotted out memories of how many Democrats had been eager for a bipartisan deal and structured health care in a way designed to get Republican votes. But because the Republicans insisted on repealing Obamacare and adopted a Republican-only coalition, Democrats dug in. Republicans then assumed they could only muster 51 votes in the Senate and therefore they had to use the reconciliation process, which then limited what kind of policymaking they could actually do.
Perhaps the main way that self-deception hurt the Republicans is more basic. Because they overstated both the badness of Obamacare and the easiness of replacing it, they got lazy when it came to making policy. Serious policy critiques could easily be swatted away as inconsistent with some bit of magical thinking. If you can cover everyone and lower premiums without having mandates or taxes, why bother to wrestle with the real trade-offs inherent in health care policymaking?
Conservatives have many legitimate arguments for why Congress should have taken a different path on health care. But their own eagerness to exaggerate or deceive made it nearly impossible for them to deliver on their promises.