Trumpcare Might Pass, But the Conservative Health-Care Agenda Is Dead

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Republicans celebrate the House passage of the American Health Care Act. Photo: Jabin Botsford/The Washington Post/Getty Images

The Senate Republican plan to unveil a health-care bill, then race it to the floor without hearings, has inspired an archival outpouring of vintage 2010 Republican complaints over the allegedly secretive passage of Obamacare (which in fact was developed in public, with dozens of hearings).

But one doesn’t need to travel back seven years to unearth Republican procedural hypocrisy. Mere weeks will do. When the House passed its health-care bill just last month, Republicans insisted that they would work slowly and carefully to craft a well-designed bill. “The Senate is starting from scratch,” said Susan Collins. “We’re going to draft our own bill, and I’m convinced that we’re going to take the time to do it right.” This promise was not confined to the party’s shriveled moderate wing but included reliable right-wingers. Lamar Alexander: “The Senate will now finish work on our bill, but will take the time to get it right.” John Cornyn: “We’re not under any deadline, so we’re going to take our time.” Tom Cotton: “Get it right, don’t get it fast. GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed.”

The current Senate Republican plan is to introduce a bill next Tuesday and vote on it Thursday. “By all accounts,” summarizes health-care reporter Dylan Scott, “Senate Majority Leader Mitch McConnell (R-KY) is agnostic about the actual policy of the bill his chamber is drafting.” The Republicans’ notion of taking their time and getting it right, rather than rushing to meet an arbitrary deadline, has been turned on its head. Why did Republicans suddenly decide to get health care done fast, not right? There is a larger point here than hypocrisy and broken promises. A short period of examination yielded the same conclusion in the Senate as the House: Republicans have realized their party is constitutionally incapable of writing a satisfactory health-care law. Whether the Republican health-care law passes or fails, an entire policy agenda has died in the process.
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Policy ideas have certain life cycles. They are developed in academic settings, incubated by policy entrepreneurs in think tanks, and groomed for candidates to run on and then, finally, implement in office. At some point they either meet the test of political viability, or they fail.

Some of the most promising-sounding ideas survive until this final stage before they die. Cap-and-trade was the hot climate-change policy, so elegant and attractive that both the Republican and Democratic presidential candidates endorsed it in 2008. But Democrats discovered the following year that it couldn’t pass the Senate, and nobody has seriously tried to revive it since. If you asked a Republican in the 1990s to name a policy idea other than tax cuts, they would probably have suggested school vouchers, which conservatives believed would enable the GOP to claim the mantle of innovation and opportunity for urban minorities. Vouchers crashed and burned at the ballot box, and ever since, Republican candidates have avoided the concept like the plague. The same fate awaited Social Security privatization, which was the next big thing in conservative policy until it failed in 2005, and now even its fiercest advocates never mention it anymore.

That is what is happening to conservative health-care policy in 2017. Over the years, and especially since 2010, the conservative movement intelligentsia has expended a great deal of energy on developing alternatives to Obamacare. The central idea they settled upon was to turn American health-care consumers into price-sensitive shoppers. Health care was failing, they believed, because its pricing mechanism was too opaque. People did not know how much they paid for health care, but if the pricing were more transparent, they would use their power as consumers to bring down costs. The solution was to give them “skin in the game,” rather than have third parties (like employers) cover all the costs for them. Health care should be priced less like fire insurance, where somebody writes you a check when emergency strikes, and more like buying a television, where the sticker price is sitting right there and you decide whether it’s worth paying more for a better product.

Liberals fiercely objected to the analytical assumptions underlying this policy goal. But the merit of the arguments is somewhat beside the point. Indeed, as we now see, it will always be beside the point. This was the moment Republicans had to finally put their ideas into practice. And the GOP decided, without any significant dissent, to ignore the policy blueprint their own wonks had spent years developing.

Why didn’t Republicans decide to write a conservative health-care bill? Because Americans don’t want one. Marketized health care with transparent pricing turns out to be literally the opposite of what the country prefers. Washington Post reporter James Hohmann travels to Georgia’s sixth district, the site of the contested special election, and finds through “dozens of interviews” that even the Republicans in this affluent district want a health-care plan that gives them less, not more, skin in the game. One representative right-wing voter hates Obamacare because, he tells Hohmann, “I have to pay a $40 co-pay just to see a doctor.” Any authentic conservative health-care program would increase, not decrease, that amount. “Their expectations might seem unreasonable to anyone who is closely following the debate or is steeped in the complexities of public policy,” reports Hohmann, “but they believe Donald Trump can and should enact a replacement plan that will both reduce their costs and improve their quality of care.” Why would they have these expectation? Because while Republican wonks have been advocating more skin in the game for consumers, Republican politicians have been promising the opposite. That is why Mitch McConnell denounced Obamacare for having the very features — high deductibles and co-pays — that conservative wonks would like to extend: “In addition to premiums going up, co-payments going up, deductibles going up. And many Americans who actually did get insurance when they did not have it before have really bad insurance that they have to pay for, and the deductibles are so high that it’s really not worth much to them.” And it is why President Trump promised vaguely to take care of everybody and give them something “terrific.”

In the face of the impossible contradiction between what their own voters expect and what they are prepared to deliver, the Republican solution has been to hide the ball. That is why they have settled on a strategy of maximum speed, minimum transparency, and flamboyant dishonesty. (“There are no cuts to the Medicaid program,” says Health and Human Services director Tom Price, when his own budget proposes to cut the Medicaid budget nearly in half.) The Senate’s concession to the concerns of its most politically vulnerable members is to delay its implementation several more years into the future (the exact length of the delay being a subject of negotiation). Republicans can’t live with the effects of their own bill, but they also don’t want to admit they can’t improve upon Obamacare.

Rather than design a health-care bill that pursued conservative priorities, they have kept the structure of Obamacare and simply drained its resources in order to finance a large, regressive tax cut. It turns out you can work pretty quickly if you don’t care about substance. Whether or not they dismantle Obamacare, the Republicans have already given the conservative health-care agenda a permanent burial.

Trumpcare Might Pass, But Conservative Health Care Is Dead