Understanding The Republican Health Care Debacle

03/26/2017 08:37 pm ET
Bloomberg via Getty Images

The first thing to remember is that the Republican position on health care, from the start, was to have NO health care legislation. They wanted to leave it all to market forces, never mind the many millions of people who had no insurance, or the insurance companies imposing, on people who did have coverage, things like lifetime coverage limits, pre-existing condition restrictions, etc.

Therefore, because the Republican position was to have NO health care legislation, when the Affordable Care Act (Obamacare, for short) was introduced, their goal was to defeat it, as they had the earlier Clinton proposal at the end of the 20th century, and remain at the status quo, even if it meant tens of millions of people would remain uncovered by insurance and, as a result, without access to health care.

But they weren’t able to defeat Obamacare. Once it passed, and they were unable to overturn it in the courts, their effort over the past seven years had to change.  Now they could no longer credibly work to repeal it, to go back to a time before it passed, to return to the situation that would have existed had they defeated Obamacare, as they had the earlier Clinton bill.  As a result, their campaign to repeal became, had to become, a campaign to repeal and replace.

This was because of an insufficiently recognized political reality: the inertia of partial progress.  This reality was perhaps best exemplified by the old Robert Moses “get the legislature to authorize the first ten miles of the 100-mile road, and it will be very difficult, and as a practical matter probably impossible, for them subsequently to refuse to authorize the remaining 90 miles, once the first 10 miles are built.”

That reality was also why, once Social Security was enacted, with all its omissions and imperfections, it has proved impossible to do away with, and it has been expanded instead.  This is because once lots of people receive benefits, they come to believe they are entitled to them, they get used to and dependent upon them, they see them as normal and as theirs by right, and even though they might not have clamored for such benefits before they were enacted, once they are enacted and people get used to them, they cannot politically be taken away, at least not easily.  This is particularly true of the benefits that inure to an electorally potent constituency.

That may have been the mistake made in 1969-1970 by liberal opponents of Nixon’s proposed negative income tax, designed at the time as an entitlement to replace discretionary welfare payments. Although the politics were complicated, and constantly shifting, at least some of the liberal opposition back then was based on the ground that the amounts of the proposed negative tax payments were insufficient. They were insufficient, but once enacted, and written into the tax code, they would have probably become less politically vulnerable than discretionary welfare payments, and the amounts probably would have increased over time.

That’s also why it’s hard, if not impossible, to eliminate mortgage interest and real-estate tax deductions for homeowners, despite the fact that it is a subsidy not provided to renters, even though they pay a portion of their landlords’ mortgage interest payments and real-estate taxes that is factored into their rents.

Benefits that are difficult, or nearly impossible, to initiate are even more difficult, if not impossible, to take away once people have them. That is why it is politically critical to initiate benefits, even if imperfectly or flawed.

Early law is like cement: once it is there, everyone has to stand on it, and build on top of it.

Thus, once the Republicans failed to defeat Obamacare legislatively, or to block it judicially, and many millions of people previously uncovered began to benefit from it, and to rely on such benefits, once such benefits became normalized and part of people’s calculus of expectations, the GOP strategy of simply repealing Obamacare, and returning to a time prior to Obamacare, became impossible. Now the Republicans stood on different ground.  The strategy of Repeal had to be changed to a strategy of Repeal and Replace. Now, if they wanted to get rid of Obamacare, they would have to do something they never had to do before: propose something better.

But as long as the Republicans were powerless to actually do anything about Obamacare except fume and fulminate and rile up their constituencies, they never had to confront the REPLACE part. That is, without control of both houses of Congress and the presidency, the distinction between “repeal” and “repeal and replace” was academic, and politically inconsequential. As long as they were powerless to defeat Obamacare, a singular strategy of REPEAL, which only required them to say NO over and over again, to pass more than 60 bills, all of them futile, repealing Obamacare, without ever having to offer an alternative to replace it, had only positive political consequences (rallying their troops with the delusion that they could return to a pre-Obamacare time) and no negative consequence, because they had no need to propose an alternative (in the pre-Obamacare time, no alternative was necessary, because the Republican position was that no health care legislation was necessary, and because no one had yet had any benefits from such legislation, there was no substantial pushback politically).

NO was enough; YES to something else wasn’t yet politically required.  And so the GOP remained united around NO.

Early law is like cement: once it is there, everyone has to stand on it, and build on top of it.

But once they gained control of both houses of Congress and the presidency, Republicans were confronted by the distinction. Now, they owned the issue. Now, they couldn’t just repeal, because now repeal by itself would strip too many people, including, critically, many of their own constituents, of benefits upon which they had come to rely. (Some of those people weren’t even aware that “Obamacare,” which they opposed, was the same thing as the Affordable Care Act, which was the source of their benefits; like the voter who screamed “Keep the government away from my Medicare!” they had no idea about the source of their benefits; but they would certainly know if those benefits were taken away, and they wouldn’t like it.)

So now NO wasn’t enough; there had to be a YES as well.  REPEAL wasn’t enough; now REPEAL AND REPLACE was politically required. The Republicans wished to go back to the time before Obamacare, but that was no longer politically feasible, for now they stood on the ground established by seven years of Obamacare, a ground not where people wouldn’t clamor for benefits they could not imagine, but rather a ground where benefits, however inperfect, already existed, and where people would be furious and politically punitive if those benefits were taken away. 

The inertia of Obamacare had altered the politics of opposing it.

Thus the Republicans now had to do something they had never done before, never needed to do before, and didn’t believe in doing: they had to come up with an affirmative plan to provide health care coverage for at least everyone that was now covered by Obamacare. 

Thus REPEAL had to become REPEAL AND REPLACE.

NO had to be accompanied by some sort of YES.

And both doctrinally and politically, they were utterly unprepared for this, in part because they never expected to have the political power of both Houses and the presidency anytime soon.

So the demagogic, scorched-earth oppositional anti-Obama strategy, which had worked to rally their electoral constituency even against its own interests, and helped vault them into power, now suddenly was transformed into the need to govern, to stand upon ground they wished to avoid and to actually do something that before Obamacare only Democrats would do: propose an affordable plan to provide health care coverage for people who before Obamacare did not have it. Now they had to come up with some sort of YES.

Saying NO united them, but saying YES split them asunder, and predictably so.

Trump, who paid no attention to details or content, and whose only goal was self-aggrandizement and whose only strategy was boasting and lying (and why not, it had worked so far!), embraced REPEAL AND REPLACE. We will replace Obamacare quickly and it will cover everybody and be cheaper, he boasted. It will be beautiful, believe me, he bleated.

MANDEL NGAN via Getty Images

And incompetent dumbkopf that he is, he probably believed it. After all, such bluster had been his life’s M.O., and had gotten him everything he had. At 70 years old, he was not about to change his ways.

Ryan, surely the most overrated member of Congress, a man driven by ambition to never miss a moment to abandon principle for complicity, a man whose economic theories are grounded in his infatuation with Ayn Rand, a man steeped in the politics of NO but utterly inexperienced and unprepared for the politics of YES, or for building legislative consensus, then whips up an imagined piece of balderdash legislation, stitched together (he thinks) to satisfy all Republican Congressional voting blocs, without hearings, without negotiations, without all of the predicates that any successful complex piece of legislation requires. 

It is, in fact, not legislation (with which he and Republicans in the House, devoted to NO, have no experience), but rather a press release disguised as legislation, hoping (naively, incompetently) to jam it through swiftly and without scrutiny.

But it doesn’t work: large portions of the medical community and even the insurance industry quickly oppose it; it is widely editorially condemned; and then, in a crippling blow, the Congressional Budget Office delivers its verdict: 24 million people who now have coverage will lose it.  Public opinion polls begin to show disastrous disapproval judgments.

The Republicans in Congress swiftly fragment. The Tea Party loonytunes, who will not compromise ever on anything, and who have eaten their own before (e.g., Boehner), take the position that, as harsh as Ryan’s bill is, it is not nearly harsh enough. There are 15 of them.  Trump calls them in, negotiates, makes some concessions that increase the cruelty of the bill, but it’s still not enough for the crazies, and their opposition remains steadfast. 15 Republicans against the Republican bill.

The so-called moderates oppose the bill because it is too harsh; many of them know their constituents will be hurt by this bill, and will lose benefits under it, and will punish them politically if they vote for it. (Reality bites, once you have power.)  There are 10 of them, and their opposition hardens once Trump makes his concessions to the crazies in a futile, last ditch attempt to appease them.

So now 25 Republicans plan to vote against the Republican bill.

Eight other Republicans also declare their opposition, for a variety of stated reasons, most at bottom probably also rooted in fears of electoral reprisal.

That’s 33 Republicans in all opposed, for opposite reasons, so despite a 22-vote Republican majority, the Ryan bill doesn’t have the votes to pass, and he pulls it.

If somehow it had passed, it was dead on arrival in the Senate, where the Republicans had an even narrower majority, and would have also been split asunder by this bill.

The new necessity of saying YES thus exposed fractures that the comfort of saying NO had papered over.

This ain’t over (it is way too early to gloat), but other complex battles over tax code revisions and the long promised Mexican wall and very ambitious infrastructure spending lie immediately ahead, and before long the spectre of the midterm elections will begin to loom. 

Meanwhile, the as yet unresolved travel ban initiative, so far stopped in its tracks by the courts, as well as the increasingly threatening Russian connection investigation, continues to contribute more chaos and frustration. 

So far, so good, for those opposed to Trump’s initiatives. But can the Democrats take advantage?  And even if they do, can they overcome the grossly gerrymandered Congressional districts that will continue to give Republican candidates a decisive advantage in the 2018 midterm elections?

Much may depend on what happens with other legislation and other issues during coming months.

But out there in Trumpland, I suspect this health care debacle has got some Republican voters wondering. And rightly so.

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