The Republicans control the presidency and have majorities in both houses of Congress, but this unified GOP government will likely neither repeal, replace, nor even much reform Obamacare. We might end up with a law that improves healthcare policy—but it would take a miracle. Why is it proving so difficult for Republicans to agree on what to do?
This isn’t the first time a majority party has had trouble passing comprehensive healthcare reform. In 1995, Democrats had large majorities in the House and the Senate (larger than the GOP’s today), as well as a president (and an ambitious first lady) who wanted to make health care a signature achievement.
The resulting proposal was a mess. Most Democratic members of Congress couldn’t understand it or explain it to a country where most people were not only risk-averse but also happy with their current health care. Does this sound at all familiar?
The Clinton proposal died, but the story didn’t end there. Democratic politicians and liberal activists went to work, learning from the political and policy mistakes of the Clintons and preparing for the next opportunity. This process took place in Congress, in think tanks, and at colleges—but also on the street, where liberal citizens took an interest in the issue and demanded answers from their politicians.
It took thirteen years, but by 2008, there was a broad consensus on the center-left about what comprehensive healthcare reform should look like. All of the major Democratic candidates that year supported proposals that looked roughly like today’s Obamacare, including a mix of guaranteed issue, community rating, heavy coverage mandates for insurers, a purchase mandate for consumers, and an expansion of the existing Medicaid system.
This proposal wasn’t every Democrat’s first choice. Some moderate Democrats would have preferred something cheaper and less disruptive. A much larger group of liberal Democrats would have liked some version of government-run single-payer health insurance. But the vast majority of Democrats agreed that what would become Obamacare was the best option at the time, and a huge improvement on the status quo. There was only one major Democratic division, and it turned out to be an invention: Obama claimed he was opposed to the individual insurance-purchase mandate, but he was lying.
Obama lied a lot about Obamacare, but he knew what he wanted. And the Democratic leaders of the House and Senate agreed with him, as did the vast majority of rank-and-file members and Democratic voters. Since a near-majority already agreed on the goals, there was a solid basis for negotiating details with holdouts. The support of most Democratic voters also formed a floor beneath Obamacare’s popularity rating. Though the law was generally unpopular, its popularity rating was usually in the forties. The current GOP would kill for a conservative proposal that could poll at 40 percent.
Where were the Republicans in all this? They were asleep. There has always been a tension in Republican politics between libertarians and pragmatists, between reformers who aren’t especially enamored with America’s healthcare system and the mass of Republican-leaning voters who are happy with their Medicare or employer-provided health insurance. The GOP has generally resolved this tension by ignoring the issue except to oppose any further expansion of government into health care. On this issue, Republicans have been held together not by principle or common understanding, but by the status quo.
I remember listening to Rush Limbaugh in the 1990s. He would become noticeably uncomfortable whenever the healthcare conversation drifted away from the perfidy of socialist Democrats and to some problem a listener was having with the actually existing healthcare system. He would usually say something about tort reform, talk about freedom, and change the subject as quickly as possible.
Limbaugh had his reasons. He isn’t in the leadership-and-principles business. He is in the audience-and-money business. As Trump demolished the version of Reaganism that Limbaugh had expounded for twenty-five years, Limbaugh sat back and watched, because he knew a large segment of his audience got a kick out of Trump. He didn’t want to alienate those listeners. When it came to discussing health care, Limbaugh didn’t want to leave his audience anxious, bored, and confused. It was easier just to talk about tax cuts, missile defense, and the follies of liberal celebrities. He knew what his audience wanted. I was part of that audience. The fault, dear Brutus, is not in our talk-show hosts, but in ourselves.
When Obamacare destroyed the status quo that had held the Republicans together on health care, the only agreement they could reach was to restore the old status quo. But as millions of Americans began getting their health insurance through Obamacare’s Medicaid expansion and healthcare exchanges, this became politically more difficult. The new status quo was the enemy of the GOP, and the country was still very risk-averse.
This is where Trump comes in. As a former supporter of single-payer health care who was obviously ignorant about policy, he should have been dead in a Republican primary. But it turned out that, for many Republican voters, it was more important that his heart seemed to be in the right place.
Trump famously said that he was not going to let people die on the streets for lack of health care. It is notable that this sentiment was expressed by Trump rather than by one of his opponents who marketed themselves as humane, civil, thoughtful, compassionate alternatives to the brutal Trump. As for the more conservative Ted Cruz, his campaign’s healthcare motto might have been, “The uninsured won’t vote Republican anyway.” As Henry Olsen has demonstrated, Trump’s was the most authentically Reaganite response on health care.
But even if Trump had some Reaganite sentiments, he didn’t—and doesn’t—have a plan. That wouldn’t be a problem, except that no one else on the right does, either. Well, there are plans, but there is no consensus on how much they should cost or what they should mandate. There doesn’t even seem to be any agreement on the purpose of the eventual plan. The Republicans are trying to repeat the actions of the Democrats in 2009 and 2010, but they are stuck in the situation of the Democrats in 1995.
They haven’t done the work—and not just they. We haven’t done the work. We haven’t figured out what we want and what trade-offs we are willing to accept. Our political leaders have ignored this issue because we wanted them to. If this Republican Congress fails to pass a good healthcare bill, we should prepare for our next opportunity to reform health care—if such an opportunity ever arises.
Pete Spiliakos is a columnist for First Things.