Limping into Another Health Care Debate

Two weeks ago, I suggested around here that the general sense that the Democrats had badly lost the government shutdown fight could turn out to be wrong:

In a confrontation they had no real shot at winning, the Democrats may well turn out to have been quite right to just use the modest leverage they had to change the subject to health care, even without the prospect of any substantive gains in the near term. After all, Republicans haven’t gained anything either. They are left with a few more months of Biden-era spending levels and another health-care debate they have no idea how to win.

That does look to be how things are going at this point. Republicans are unsure how to proceed regarding the expiring Covid-era Obamacare subsidies, and that uncertainty is revealing two kinds of problems they have sought to obscure all year.

The first is just the sheer absence of any Republican health care agenda, which has been a persistent problem for more than a decade now. Republicans have honed the habit of starting sentences they can’t finish when it comes to health care, promising all sorts of action if only they could get the leverage to advance it, but then turning out to have no particular policies in mind — or at least none they agree about.

In this instance, the administration’s proposal (which built on ideas advanced by several Republican senators) was basically to extend the existing subsidies with a few more constraints. They wanted subsidies available only for households that make up to about $225,000 a year (!), for instance, and they treated that as a substantively significant health care reform. But it’s really just a trimming of the status quo. Republicans aren’t pursuing any kind of different direction on health care policy, and it’s not because they don’t have the votes to advance one but because they don’t have any generally agreed-on ideas to advance.

Now, to be fair, the Democrats have no reform ideas either. They seem untroubled by the utter economic irrationality of Obamacare, as they have been from the start. And their response to the fact that the system has turned out to be so dysfunctional that it can only persist by heavily subsidizing families that earn almost three times the median income is just to fund those subsidies (and not even limit them by income at all). But the Democrats don’t pretend to be troubled by the cost of all this, and so they aren’t tying themselves in knots about it.

The second problem revealed by the Republican fight over health care is one the GOP has been even more eager to obscure this year. It is the great and growing frustration with the Trump administration among congressional Republicans.

In some ways, that frustration has been evident from the start. Capitol Hill Republicans have tried to talk like down-the-line Trump supporters all year, but they have resisted the administration’s fiscal agenda, grumbled about its unilateralism, and (in the case of the Senate) also rejected a large number of presidential nominations. As of today, President Trump has had to withdraw a record 51 nominations for Senate-confirmed positions this year, the great majority of them because Senate Republicans informed the White House that the nominee did not have enough support among them to be confirmed. It is in no one’s interest to highlight this striking pattern, so it hasn’t really become part of the narrative of Trump’s second term, but it should.

The latest health care debate has forced this frustration to the surface in an unusual way, though. This week, for instance, when the White House let it be known that the president was about to publicly propose the abovementioned modified extension of the Obamacare subsidies, congressional Republicans unceremoniously forced the president to back down.

The open conflict between President Trump and Representative Marjorie Taylor Greene about the subsidies has revealed some similar fissures. On the face of it, this was a show of force by Trump, forcing Greene to leave Congress because she had broken with him. But Greene’s stated rationale — that the GOP’s approach to governing in the Trump era leaves members of Congress with nothing to do and is a betrayal of the constitutional order — has landed on Capitol Hill in a peculiar way. As Punchbowl’s Jake Sherman noted, a number of House Republicans reacted to Greene’s decision to leave Congress with a mix of envy and sympathy and with a lot of frustration directed at the administration. Sherman quoted one member he called a “senior House Republican” saying:

This entire White House team has treated ALL members like garbage. ALL. And Mike Johnson has let it happen because he wanted it to happen. That is the sentiment of nearly all — appropriators, authorizers, hawks, doves, rank and file. The arrogance of this White House team is off putting to members who are run roughshod and threatened. They don’t even allow little wins like announcing small grants or even responding from agencies. Not even the high profile, the regular rank and file random members are more upset than ever. Members know they are going into the minority after the midterms.

That frustration with the White House legislative affairs team is very widespread on Capitol Hill. Members feel personally disrespected. But the problem runs particularly deep because it is a function of the administration’s general approach to Congress and indeed to governing. From the beginning, this White House has seen dealing with Congress as just an unproductive headache and sought for ways to govern without a legislative agenda. That search has failed, because there can’t actually be a way to govern durably without a legislative agenda in our system, but the administration still seems unwilling to see that.

And the problem has revealed itself with particular force in the health care debate because health care doesn’t lend itself to this administration’s preferred mode of action, which is retail dealmaking with individual institutions rather than wholesale policymaking. The White House has tried some retail bargaining on the health front — making deals for lower prices with particular pharma companies and the like. But that just can’t get very far. Health care requires wholesale policymaking, and the Trump administration appears not to be equipped for wholesale policymaking, at least outside of immigration policy.

Congressional Republicans also seem increasingly aware that President Trump is not offering them meaningful political cover. As the president’s public approval plummets, others in the party seem increasingly to grasp that being led by an unpopular lame duck is going to require them to put some distance between themselves and him. So far, that only means distance from the White House in general. In time, they will no doubt need to find new ways to talk about Trump himself too.

All of this adds up to a challenging environment for Republicans. But it is worse than it has to be. The GOP enjoys some very significant advantages in public opinion on key issues at this point. In fact, the only top-ten public concern on which the Democrats have a significant advantage is health care. And yet somehow, it is health care that looks to be the dominant issue as the midterm election year gets going.

So who won the shutdown?