On Obamacare, Republicans once again find themselves uniting the country — against them.
Conservatives believe their party’s congressional leaders have sold out. Non-conservatives think they are dangerously right-wing.
Conservatives say Republicans are creating a new entitlement without paying for it, a reckless expansion of the welfare state at a time when the country is going broke. Non-conservatives claim the recklessness lies in the GOP’s evisceration of the social safety net and health insurance programs on which millions rely.
We’ve seen this movie before. Think of the budgets conservative groups campaigned against as bloated, fiscally irresponsible messes while respectable center-left newspapers characterized them as Ebenezer Scrooge demanding, “Are there no workhouses?”
Conservatives see President Trump as the most liberal Republican chief executive since Richard Nixon was imposing wage and price controls in the 1970s. Non-conservatives believe the phrase “to the right of Attila the Hun” was coined to describe the current occupant of the White House.
The Obamacare replacement bill is as good an example as any of what Republicans are up against. The GOP needed to satisfy their base’s demand to repeal Obamacare without upsetting too many other voters’ existing healthcare arrangements; win votes from lawmakers who want to curb Medicaid spending and lawmakers who want to maintain Obamacare’s Medicaid expansion; cut spending and regulations while maintaining comparable benefits; cut taxes without letting costs get out of control; all with many fewer votes to spare than when Democrats passed Obamacare in the first place.
So it is not surprising that the end result does not reduce the federal government’s role in healthcare as much as conservatives would like while probably failing to cover anywhere near as many people as Obamacare did.
The dilemma for conservative Republicans is that the country tends to vote for them for the same reason a circus hires people to run with brooms behind the elephants. Somebody has to clean up the mess left by Democratic excess.
But the people running behind the elephants don’t get to write the program for the circus and conservative Republicans don’t often get to plan the default path of the federal government.
When liberals run the government with a modicum of competence, they are difficult for conservatives to beat. When they go too far, Democratic bastions like New York City can elect a Rudy Giuliani.
Even Ronald Reagan’s election is hard to imagine in the absence of stagflation, a loss of confidence in the ability of liberal governments to control crime or protect national security and a series of international embarrassments while the Cold War raged.
While Beltway Republicans roll their eyes at social issues and culture war politics, it is the divide over these topics that has helped keep the GOP in the game. When it comes to a conservative vision of the welfare state, it is not entirely clear conservatives even have the buy-in of their own voters.
Trump was elected in spite of that conservative vision, not because of it. Most debates over the size and scope of the federal government occur on liberal terms, with conservatives trying to control the costs.
On healthcare, it is even worse. Conservatives spent decades arguing against high marginal tax rates, burdensome regulations and overly generous welfare spending before finally breaking through with the public.
Few people outside of conservative policy wonk circles are familiar with what a free-market alternative to government healthcare would look like. Remember that Republican presidential debate where Marco Rubio made fun of Trump for not being able to explain what is healthcare plan would entail besides erasing the “lines around the states?”
The average Republican politician would not do that much better than Trump. The GOP has largely run against Democrats’ attempts to increase the government’s role in healthcare, occasionally acquiescing just enough to fight off bigger liberal programs (think SCHIP and Medicare Part D).
Obamacare’s exchanges have plainly not worked for many people, creating a constituency for repeal. But imagine how weak that constituency would be if Obamacare was just Medicaid expansion.
Medicaid has serious financial problems and the quality of healthcare its beneficiaries receive is questionable, largely due to the low reimbursement rates for doctors. A Republican-controlled Congress is nevertheless having a hard time rolling it back.
This lesson won’t be lost on the Democrats next time they get to tinker with the healthcare system. The exchanges are a mess of government regulations and spending. But the Democrats intended them as a concession to the free market, and they are associated with the least popular parts of the law.
Four years ago, I published a book detailing how conservatives could roll back the growth of government. I argued they would need the right Republicans to get elected, be willing to take some political risks and then experience a little bit of luck.
Maybe that good luck streak is coming soon, but it doesn’t look like any of these developments have occurred in the battle to repeal and replace Obamacare.
