The collapse of the American Health Care Act has Republican pointing fingers in all directions. Some want to blame the House Freedom Caucus for opposing an Obamacare repeal that did not repeal enough of Obamacare. Some want to blame Republican moderates for opposing any repeal that would have thrown too many people off the insurance rolls. Everybody seems to be blaming the GOP congressional leadership. I would suggest that we spend too much time thinking about GOP health-care policy in terms of liberals, moderates, and conservatives. The real problem is that, on health-care policy, most Republicans are neither conservative, nor moderate, nor even liberal.
Sometimes it makes sense to talk about political cleavages in terms of a left–right spectrum. On taxes, conservatives want less and liberals want more. There are other axes of disagreement (flat taxes, progressive taxes, consumption taxes, payroll taxes), but the generalization holds true. It is the same on guns. The left position is greater restriction on the private ownership of guns, while the right position involves fewer restrictions on private gun ownership. You can be to the “left” on one issue but to the “right” on another. Prior to running for president, Bernie Sanders was to the left on taxation and most other issues, and to the right (relatively) on guns.
It is possible to speak of intra-party GOP health-care debates in terms of an ideological spectrum. On the right, you have conservatives who would accept a full repeal of Obamacare even in the absence of a replacement. They are willing to accept that millions would lose coverage to be a price worth paying. On the left, there are Republican moderates who are so supportive of Obamacare’s coverage expansion, and so fearful of getting rid of some popular Obamacare regulations, that they are basically willing to let the law stay as it is.
In the middle, you have a group of reformist conservative wonks who want to replace Obamacare with a combination of universally available catastrophic health-care insurance (through automatic enrollment of the uninsured combined with an opt-out clause), health savings accounts (pre-filled for the indigent), and high-risk pools for that portion of the uninsured with pre-existing conditions. This is to be combined with market reforms to force medical providers to be open about their pricing and the elimination of barriers for new medical providers.
Unlike the Republican Left, this middle group hates Obamacare for worsening everything that is already broken about America’s system of using third-party insurance as comprehensive pre-payment for routine health-care costs. Unlike the Republican Right, they accept that market health-care reform that expands catastrophic coverage is going to involve higher government spending than the pre-Obamacare system does.
If it was just these three groups, we might be fine. People who hold each of these viewpoints can have a productive conversation. There might be a compromise, or one side might prevail.
The problem is that most GOP voters (and, I would suggest, most GOP members of Congress) are nowhere on that ideological spectrum. They don’t like Obamacare, but they also don’t like the trade-offs involved in any of the Republican left, right, or center alternatives to Obamacare.
No, that’s not quite right. It isn’t just that they don’t like the trade-offs. It is that they don’t want to think about the trade-offs — or even to think about health-care policy at all.
It didn’t start this year. It didn’t even start with Obamacare. Rank-and-file conservatives have been uncomfortable talking about positive health-care-reform proposals for decades. They could explain to you why missile defense systems and capital-gains tax cuts were good, but when they were asked about alternatives to Democratic health-care plans, things got awkward. There was mumbling about tort reform, followed by some way to derail the conversation.
These Republicans were comfortable attacking Democratic proposals but could not agree on any alternative and did not want to think about any alternative. America already had the greatest health-care system in the world — until Obama messed it up.
That was the formula. Praise American health care, attack the Democrats for wanting to socialize medicine, and change the subject as quickly as possible.
The passage of Obamacare made that strategy obsolete, but the habits didn’t die. This group spent seven years opposing Obamacare without thinking about what a post-Obamacare health-care policy should look like.
Much more than the House Freedom Caucus, or the skittish moderates, or the wonks, it is this last (and largest) group that sets the tone for the GOP on health care. Like this largest, unideological group, Republicans spent seven years failing to agree on even the broad principles of an Obamacare replacement, spent a few weeks flailing around, and now want to use the failure of the AHCA as an excuse to move on to real issues like tax reform. The GOP was never more itself than when its response to failure borne of the refusal to think seriously about health care was to think about something (anything) other than health care. For the average Republican, health care is nails on the chalk board. Tax cuts are a warm bath.
We will know that the Republicans are serious about health care when the great mass of Republicans shake off the habits of the last 40 years and pick a side on health care policy.