Why Republicans are losing the health care fight, and how they can win in the end.

Why Republicans Are Losing the Health Care Fight (and How They Can Win in the End)

Why Republicans Are Losing the Health Care Fight (and How They Can Win in the End)

Who's winning, who's losing, and why.
July 7 2017 10:54 AM

Why Republicans Are Losing the Health Care Fight

And how they can win in the end.

Senate Majority Leader Mitch McConnell speaks.
Senate Majority Leader Mitch McConnell speaks in Elizabethtown, Kentucky, on June 30.

Bryan Woolston/Reuters

What happens if Senate Republicans can’t get the votes they need to pass the Better Care Reconciliation Act, the latest GOP effort to partially repeal and replace Obamacare? Senate Majority Leader Mitch McConnell, the chief architect of the BCRA, has been hinting that if he can’t unite the GOP caucus, he’ll have no choice but to work with Senate Democrats to shore up topsy-turvy insurance markets, which have been destabilized by all the uncertainty around whether Obamacare’s subsidies and regulations will survive. This could just be a scare tactic McConnell is using to keep Republicans in line—a way to tell GOP hardliners that if they don’t get on board with the BCRA, he’ll pivot to cutting a deal with moderates in both parties that would leave them out in the cold. Or it could be a frank acknowledgment that if Obamacare is here to stay, Republicans will have to take ownership of it. Either way, if the BCRA goes down, the GOP will have to do a lot of soul-searching.

The Republican fight against Obamacare has always been about more than Obamacare. It was, from the very beginning, more of a symbolic struggle about the size and role of the federal government. I say symbolic because while Obamacare was always expected to cost meaningful amounts of money, the real drivers of federal spending in the decades to come are public insurance programs that were established long before Obamacare, like Medicaid and Medicare. Though Obamacare greatly expanded Medicaid, it also sought to restrain future increases in Medicare spending. There was some irony in the GOP’s anti-Obamacare zeal, as many Republicans voted for the expansion of the Medicaid rolls and the creation of the Medicare prescription drug benefit in the early 2000s, among other measures that greatly expanded government’s footprint. But these expansions of public insurance programs could always be characterized as modest and incremental ways to patch up the safety net, which posed no real ideological threat.

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Had Democrats proposed yet another expansion of Medicaid, it’s possible they would have peeled off a few more Republican votes and sparked less of a backlash. But Obamacare was all about Democrats getting out of the defensive ideological crouch they’d been in since the Reagan era. To its champions, the Affordable Care Act represented the culmination of decades of hard work by liberal politicians stretching back to Harry Truman, if not further into the past. At long last, the federal government would take responsibility for ensuring that every American, or almost every American, had health insurance. As Joe Biden put it, Obamacare was a “big fucking deal,” and Republicans agreed with him.

Opposing Obamacare meant believing the expansion of government was not inevitable—that if Republicans stuck to their ideological guns, they could reverse the growth of federal spending and the federal bureaucracy. GOP victories in the midterm elections of 2010 and 2014 reinforced the sense that voters could be mobilized by calls for smaller government and more freedom. The trouble is that GOP victories in 2010 and 2014, like Democratic victories in 2006 and 2008, were less about swing voters’ deeply held ideological convictions than a desire to punish the party in power. More broadly, what Republicans failed to understand is that while many voters oppose big government as a matter of abstract principle, they tend to embrace expansions of government in practice, especially when they hear horror stories about what happens when the safety net shrinks.

To reverse the growth of government, Republicans would have to do more than win majorities in both houses of Congress. They’d have to reverse much deeper shifts in public opinion. Consider cigarette smoking. In How Change Happens—or Doesn’t, political scientist Elaine Kamarck notes that a half-century ago most Americans didn’t see smoking as a public problem. They might acknowledge that smoking is bad for you, and they might go even further and accept that widespread tobacco use caused problems for society at large by, say, increasing health care costs that would eventually have to be borne by taxpayers. Nevertheless, most people believed smoking was at worst a private vice and that it wasn’t the government’s business to paternalistically nudge people into quitting the habit. As time went by, activists and policy entrepreneurs succeeded in changing how people perceived smoking, transforming it in the public mind into an epidemic that threatened society’s collective well-being. The same Americans who once believed that an individual’s predilection for smoking was none of the government’s business came to believe government can and should aggressively tax and regulate cigarettes with an eye toward liberating smokers from their addiction. An idea that was once seen as obscenely intrusive eventually became the conventional wisdom.

Similarly, a century ago the fact that some young people struggle to pay back their student loans might have been seen as a private tragedy rather than a priority for the federal government, not least because the number of young people going to college was minuscule. The same goes for highway deaths or job losses due to technological innovation or air pollution. All of these things might have been seen as bad or unpleasant, but they weren’t really issues anyone expected the federal government to take on. The federal government concerned itself with regulating the railroads and tariffs and national defense, not the fact that someone somewhere in Akron, Ohio, was facing sky-high medical bills. When small-government conservatives look back longingly to the days of Calvin Coolidge, when America’s central government was comparatively tiny, what they’re really doing is lamenting that in the decades since, an endless cavalcade of problems that were once seen as purely private have come to be seen as public.

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Blame this transformation of private problems into public ones on the Great Depression or World War II. Blame it on savvy political entrepreneurs who figured out how to make every problem government’s problem. Blame it on anyone or anything you’d like. The fact remains that once a problem gets “governmentalized,” it is extremely difficult to degovernmentalize it. When you don’t degovernmentalize a given problem in the public imagination, the only way you can oppose an expansion of government power is to propose an alternative that you can sell as cheaper or more effective. Otherwise, any policy victories will be short-lived.

Which leads us back to Obamacare. To convince voters that we ought to repeal and replace it, Republicans need to recognize that most of the country now believes that providing all, or almost all, Americans with health insurance is the responsibility of the federal government. That won’t change even if McConnell manages to threaten and cajole enough Republican senators into passing unpopular health reform legislation. All it will mean is that voters will revolt, and the BCRA will wind up paving the way for single-payer.

To be truly effective, small-government conservatives need to operate on parallel tracks. In the short term, they need to recognize that the deck is stacked against them and that they need to fight for incremental reforms that nudge government in the direction of greater cost-effectiveness and transparency. At the same time, they need to do the long-term cultural and political work of fostering a world in which public problems grow small enough and manageable enough to become private problems once again. Doing these two things at once will be challenging. But it’s a hell of a lot smarter than just beating your head against a wall.

If the GOP is going to sell a repeal and replace plan, it has little choice but to offer universal coverage in some more attractive package. Selling a plan that promises anything less than that will require convincing people that guaranteeing universal coverage isn’t the federal government’s business. That’s not an impossible task over a long enough time horizon. I can imagine a world in which years of robust wage growth leave families feeling so flush that they feel they can take responsibility for their own health needs and that they can get by with less of a safety net. Alas, that’s not the world we’re living in now.

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