Ezra Klein exposes this fundamental conflict underlying the GOP's belly-flop on health care on vox.com.
The most interesting policy argument in America right now is the debate between conservatives’ real position on health care and their fake position.
The fake, but popular, position goes something like this: Conservatives think everyone deserves affordable health insurance, but they disagree with Democrats about how to get everyone covered at the best price. This was the language that surrounded Paul Ryan and Donald Trump’s Obamacare alternative — an alternative that crashed and burned when it came clear that it would lead to more people with worse (or no) health insurance and higher medical bills.
Conservatives’ real, but unpopular, position on health care is quite different, and it explains their behavior much better. Their real position is that universal coverage is a philosophically unsound goal, and that blocking Democrats from creating a universal health care system is of overriding importance. To many conservatives, it is not the government’s role to make sure everyone who wants health insurance can get it, and it would be a massive step toward socialism if that changed.
This view provided the actual justification for Ryan and Trump’s Obamacare alternative — it’s why they designed a bill that led to more people with worse (or no) health insurance and higher medical bills, but that cut taxes for the rich and shrank the government’s role in providing health care.
There was, for decades, a logic to the GOP’s dual positions: the fake but popular position was used to pursue the ends of the real but unpopular position. But in the post-Obamacare world, the chasm that has opened between conservatives’ fake and real positions has become unmanageable, and how — or whether — conservatives resolve it has become perhaps the most interesting public policy question going today.
It is notable, then, that the “conventional conservative view” is so utterly absent from the rhetoric of top conservative politicians. It is part of my job to be a close listener of Republican statements on health care policy, and they virtually never admit that universal coverage is not a conservative goal, nor do they defend the idea that freedom is the ability to choose to not be able to afford health insurance.
Instead, Republicans carefully use terms like “universal access to health care” as a way of sounding like they’re endorsing a world where everyone has health insurance even when they’re not. Top Republicans,including Mitch McConnell, spent years arguing that the Affordable Care Act wasn’t covering enough people with sufficiently generous health insurance. Then the GOP elected Donald Trump, whopromised“we’re going to have insurance for everybody” with “much lower deductibles.”
This conflict between Republican rhetoric and policy is not new and is not confined to health care. Presidential scholar Bruce Buchanan of the University of Texas at Austin has described George W. Bush as using "centrist rhetoric to cover hard right policy." The GOP's problem is that its signature policies (tax cuts for corporations and the wealthy, pre-ACA status quo on health care, deregulation, ignoring climate change, militaristic foreign policy) are deeply unpopular.
Its solution to this problem has been to lie. This strategy has been politically successful but a governing disaster. Once Republicans get into office and implement their real policies, things go very badly (e.g. tax cuts ruining Kansas and Louisiana state budgets, Bush administration fiasco) and their poll numbers tank.
The Democratic party's major failure has been in making a convincing case in exposing this dishonesty and the abysmal governing it conceals.
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