The collapse of the Republican health legislation was less surprising than a logical step in a political process that began well before Donald Trump became President or Barack Obama proposed what became the Affordable Care Act (ACA). Health care should be enshrined as a right for all Americans, ideally through a single payer system, but we never really had that debate, partly because Republican opposition was so political. Trump embraced those politics with barely a thought about the actual policies or the people needing care. This put him squarely within the recent GOP trend, tied to the takeover of the party by its right wing, of politics almost completely distorting policy in the service of winning elections.
Conservative Wishful Thinking
In the last few decades GOP leaders and operatives have emphasized certain issues mainly as a tactic for winning elections, not because they were fully thought-out policies. Examples include the preeminent importance of deficit reduction; the idea that tax cuts generate higher revenues; and the notion that government should be run like a business. Though a few issues Trump has championed, like opposing free trade, fall outside mainstream conservatism, he’s a natural result of this political trend. He certainly bought into deficit and tax cutting rhetoric, and he touted his business background as a reason to support his candidacy. Though the reality is that many of these concepts are little more than wishful thinking, because they fit nicely into conservative orthodoxy Republicans keep coming back to them. This is true even when analysis or actual events unmask them as lacking substantive validity. In some cases, by their own actions Republicans show they don’t really care about them.
For example, deficits went up under recent Republican Presidents like Ronald Reagan and George W. Bush while trending downward under Bill Clinton and Obama, once the financial crisis began to ebb. The elder President Bush did contribute to deficit reduction through a tax increase he signed, which may have cost him reelection. On taxes, there are decades of research and empirical evidence that show cutting taxes mostly just reduces revenue available to the government. Folks on the right like this result because it helps “starve the beast”, but it certainly doesn’t increase revenue. As for running the government like a business, progressives believe government can be a positive force for change, particularly in helping lower income people. Rather than ceding that point and then debating each program or issue -- where they would be at a disadvantage given popular support for so many programs -- conservatives over-argue the case and say that the private sector is always better than government. Of course they say this even while they continue to support government in many areas, in plenty of cases in ways that are intrusive or disrespectful of individual rights.
It would be nice for conservatives if these theories panned out, but they don’t have to, since their main purpose is to help win elections. Sadly, in many cases they have been effective electoral tools (that seems true of ACA opposition). Over time, they have become virtual articles of faith not only for millions of voters, but also for rank and file Members of Congress. Many in both groups don’t see that these policies were not really intended as serious legislative ideas. The end result has been a sizeable chunk of Congressional Republicans locked into right-wing positions without any openness to compromise.
Why Republicans Opposed the ACA
With the GOP now controlling Congress and the Presidency we have a test of whether conservative policies developed primarily as electoral tactics can be transformed into meaningful governing ideas. On the ACA, many conservatives opposed it purely for political reasons – they didn’t want to give Obama and the Democrats a “win”, and they didn’t want the notion that government could help solve problems to gain currency. Others claimed to oppose it for bogus policy reasons: they said the ACA was a government “takeover” of health care or that it created “death panels.” Once the ACA became law, opposition morphed into a mantra, repeated uncritically, with little apparent need for anyone (even journalists) to explain the reasons behind the repeal effort. One valid reason to favor a different approach – that the ACA covers fewer people than a single payer system would – was rarely mentioned.
The dozens of previous repeal efforts turned out to be all the Republicans had. They turned “repeal” into “repeal and replace” to avoid total embarrassment, but it was obvious their heart wasn’t in “replace,” and they gave it little serious thought. With Donald Trump – despite his vaguely socialistic comments about covering more people than the ACA – equally uninterested, it was almost a foregone conclusion that they would trip over their own legislative feet.
It became especially obvious they had no substance to their repeal proposal when we saw two central ACA concepts – barring insurance denial for pre-existing conditions and keeping children on their parents’ plans to age 26 – supported by many GOP Members and Trump himself. This meant their bill wasn’t a “repeal” measure at all, since it retained two important and popular ACA provisions. In the end Republicans merely offered an alternative way, unaffordable for many lower income people, to fund these two provisions.
One More Reason Behind ACA Opposition
This political view of ACA opposition seemed to more or less explain everything, including the Administration efforts to sabotage the law by executive order. But I had a nagging feeling there was another reason lurking behind conservative ACA opposition. The dark underside of conservatism, when everything else is peeled back, is that true believers don’t want government benefits going to those they deem “undeserving.” This could be Mitt Romney’s 47 percent “takers,” Ronald Reagan’s welfare queens, or some other segment of the population that needs Ayn Rand-ish schooling. This is a prime driver for conservative efforts even when it hurts their brand, which seems true for the failure of ACA repeal.
We saw this with the 2008 TARP bill drafted in response to the financial crisis. During floor debate, House Minority Leader John Boehner criticized the bill because it might offer mortgage help to some underwater homeowners who were, from his perspective, undeserving. He made it clear that he opposed the bill because it was impossible to guarantee only deserving people would get help. Most Democrats took the view that it was acceptable to potentially help a relatively small number of people who might not deserve assistance (however that was defined) in order to throw a lifeline to a much larger group facing financial devastation through no fault of their own. The Boehner remarks crystalized a crucial difference between conservatives and liberals, and today an unwillingness to give even modest help to people seen as takers is still a major motivation for conservatives.
On health care, it’s barely necessary to point out that, if the GOP bill had passed, it would have pulled back health insurance from millions of people who were only able to get it because of the ACA. A crucial ACA component – imposing a penalty on healthy people who can afford insurance but don’t sign up – underlies many conservatives’ opposition: yes they’re against helping folks who may be undeserving, but especially by taxing those who aren’t “takers.”
Before Trump became President, 19 states rejected new Medicaid funding under the ACA because – well, either because they didn’t want to give Obama a win or because they didn’t want to help poor people get coverage. More recently, as Kansas stumbled toward passage of legislation to embrace increased Medicaid funding, Governor Brownback’s veto focused on his opposition to helping “able-bodied adults.” In other words, he didn’t want to help Kansas residents he defined as “undeserving.”
Joan Walsh wrote in The Nation on March 27 that “[s]o-called moderates at least see a role for the government in providing healthcare, using mostly market solutions. The Freedom Caucus wants to take a hammer to government programs including the ACA, believing the market can and will provide.” I see it differently – I think the Freedom Caucus and plenty of other Republicans wouldn’t mind if it turned out the marketplace could provide (just as they wouldn’t mind if tax cuts produced higher revenues). But there’s little serious evidence they truly care about the outcome. For many in the GOP, people without health insurance are undeserving takers, and they can fend for themselves. If the Invisible Hand gives them a helping hand, so be it, but if not, it wouldn’t be the end of the world.
Sadly, because many conservatives have a hard time empathizing with others they often fail to appreciate factors outside people’s control that disadvantage them financially. Most poverty isn’t about people being lazy. Bankruptcies and homelessness are often tied to serious health problems or job loss. And sometimes, poverty is connected to government programs in ways conservatives wouldn’t imagine.
For example, plenty of people in my generation justifiably celebrate their parents or grandparents having purchased a small house, and then later a bigger place, and using the equity gained that way to fund college educations for their kids or other lifestyle improvements. Some may wonder why other Americans didn’t do the same. If you’re talking about the millions of homes financed by the Federal Housing Administration or many private banks, they had policies for decades that literally barred assistance to African Americans or members of other minority communities. Federal policies allowed this blatant bias against black people that significantly diminished their ability to share in the American dream. It had nothing to do with the alleged character flaws of the 47 percent.
Ultimately, we don’t know if ACA opposition was mainly about politics or not wanting to help the “undeserving.” Either way, conservatives are starting to find out, if they didn’t already know it, that lots of people -- not just liberals -- don’t agree with their agenda. Even moderate House Republicans opposed the health bill. Meanwhile, Trump’s habit of backing away from campaign promises has reduced his support according to recent polls to as low as mid-30 percent approval levels. Reports of interviews with voters in that group suggest many will still support him even if they lose their health care. Presumably they backed him for other reasons. This is no surprise, because the Republican ACA repeal effort, like the others pushed primarily for political or electoral purposes, wasn’t a serious legislative policy.
What’s next? Either the ACA remains in effect, perhaps weakened by Trump administration sabotage, or people lose coverage. The idea that the GOP will magically discover a way to increase coverage at lower costs seems as unlikely as that they might embrace single payer. The key question is whether the policy emptiness shown by Republicans and Trump on health care will transfer to other issues. If it does, then continued gridlock will be the likely result, despite GOP control of Congress and the Presidency.