Donald Trump added his own signature dose of shamelessness to the Republicans’ shameless crusade against Obamacare.
“We’re going to have insurance for everybody,” Trump told the Washington Post after the election. Under Trumpcare, according to Trump, people “can expect to have great health care. It will be in much simplified form. Much less expensive and much better.”
This was bolder and brasher than what more establishment-minded Republicans had said over the years. But it was, fundamentally, similar to promises and insinuations made by Paul Ryan, Mitch McConnell, and dozens of other Republicans. It’s not just that the Affordable Care Act was killing jobs and sentencing people to death panels. It’s that Republicans had some much better plan in their back pocket that would give Americans what they want — cheap, comprehensive health insurance that offers them oodles of choice.
It was a great line, and it helped Republicans win Congress and eventually the White House. But it was a lie, and now Trump and Republicans in Congress are paying for it.
Policy-minded conservatives have serious criticisms of President Obama’s health care law. They think it taxes rich people too much, and coddles Americans with excessively generous, excessively subsidized health insurance plans. They want a world of lower taxes on millionaires while millions of Americans put “skin in the game” in the form of higher deductibles and copayments. Exactly the opposite, in other words, of what Republican politicians have been promising.
And this, more than tensions between the conservative and moderate flanks of the caucus, is why the prospect of actually legislating has brought the GOP to a crisis point. The chasm between what they’ve been saying they want to do and what their policy ideas actually do is simply much too large to be bridged.
Republican leaders and conservative intellectuals, for the most part, didn’t really believe nonsense about death panels or that Obama was personally responsible for high-deductible insurance plans. What they fundamentally did not like is that the basic framework of the law is to redistribute money by taxing high-income families and giving insurance subsidies to needy ones. The details matter enormously to everyday people, but the broad principle is enough to make conservatives reject it.
They were taking a completely genuine conservative policy critique of the law — that it was making things a little too cushy for people, so they might decide to quit working — and turned it into roughly the opposite argument, that the Obamacare jackboot was going to prevent people who wanted jobs from finding work. The habit of doing this repeatedly — not just saying things that aren’t true, but refusing to state Republicans’ actual objections to the law — is what has painted the Republican Party into a corner.
It would be relatively simple for the federal government to give everyone lower deductibles and copayments by agreeing to pony up more money for subsidies. Other left-wing ideas include introducing price controls for prescription drugs, adding a “public options” whose payment rates would be linked to Medicare, letting older patients buy in to Medicare, or the wonk set’s favorite answer, “all-payer rate setting.”
But none of these ideas would address the Republican Party’s actual problems with the Affordable Care Act.
For starters, if you think the ACA’s taxes are both immoral and disastrous for long-term economic growth, then you need to repeal them. That leaves you with less money to go around to offer coverage. Couple that with the concern that generous subsidies for the poor create a disincentive to work, and you are pretty much locked into the idea that you need to make people’s insurance coverage worse.
The GOP has long had a variety of replacement plans floating around, which differ from one another in important ways. But they all cut taxes and reduce spending. They all end up covering fewer people, and they all end up delivering skimpier coverage to most of the people they do cover. In most cases, they do manage to jigger the costs and benefits around so that there is at least a subset of the population — young, healthy, non-poor people — who end up better off.
But that’s just another way of saying that the Republican plans end up giving people lower-quality insurance coverage. Young, healthy, middle-class people don’t particularly need high-quality insurance coverage, so they can benefit from a scheme that doesn’t give it to people. And one certainly could imagine Republicans trying to build a politics around the idea that having the rich subsidize the poor and the healthy subsidize the sick is a bad idea. But not only have they spent the past seven years failing to do so, they’ve actually done the opposite — running for office with the promise of better coverage while the boys in the back room cook up plans that offer worse coverage.
In the months since Election Day, it has become increasingly apparent that a reasonably large number of Republican Party legislators either didn’t understand that the campaign against Obamacare was based on lies or else had never really considered the implications of that reality.
Either way, the problem with passing a law that is going to make people’s health coverage worse while promising that it will get better is pretty obvious: People will notice when they lose insurance or when their deductible skyrockets.
They will also hear stories from friends, relatives, and co-workers.
Doctors, hospitals, and other health care providers are also going to notice that their patients don’t have the money to afford coverage. You can win an election based on a lie. You can even pass a bill based on a lie if you want. But you can’t expect that you’re going to get away with it.
Which is why, over time, GOP replacement plans keep evolving to look more and more like the status quo. The less the replacement actually changes things, the less obvious it is that Republicans have broken their promises to deliver better coverage for the American people. But even the current watered-down version of repeal still has analysis anticipating that millions of people will lose coverage, while the value of the coverage for those who remain is reduced. That leaves the GOP caught between ideological stalwarts who are alarmed by how much of the Obamacare framework the plan leaves in place and nervous pragmatists who are worried about how much suffering it inflicts.
Conflicts between purists and pragmatists are nothing new in the legislative space. But the profound dishonesty underlying the repeal campaign makes this something special. It’s not a question of half a loaf versus holding out for the whole thing. It’s a question of whether Republicans should try to deliver on their ideas or try to deliver on their promises, in a world where their ideas are antithetical to what they’ve promised. And there’s no way out.
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