The Republican drive to repeal Obamacare is not yet dead, but its state of distress is sufficient to set off recriminations on the right on its presumed failure. The most popular explanation emerging on the right is that Republicans erred by promising Americans too much coverage. “The problem for Republicans,” argues Peter Suderman, “is that they have not yet backed away from universal coverage rhetorically.” Philip Klein laments “a fatal concession made to liberals: the decision to take Obamacare’s approach to pre-existing conditions.” They argue that the party should instead have designed a stingier program, with catastrophic coverage, rather than make commitments they couldn’t carry out. What’s missing from the arguments is any serious analysis of why Republican rhetoric fudged the universal coverage question.
Since Obamacare passed Congress in 2010, Republicans have had two presidential elections to sell America on their alternative vision. When Mitt Romney lost the 2012 election, thus closing out the Republican Party’s only opportunity to repeal Obamacare before its coverage expansion took effect, conservatives theorized that Romney’s history prevented him from making the necessary full-throated denunciation of the hated law. (To wit, Erick Erickson: “He did not articulate strong fiscal conservatism and he never repudiated Romneycare, thereby failing to make any credible attacks on Obamacare.”)
Four years later, Trump ran as an opponent of Obamacare, but he hardly embraced an authentic conservative stance. Instead he made extravagant promises of more generous coverage, like “I am going to take care of everybody … Everybody’s going to be taken care of much better than they’re taken care of now.”
It is not merely bad luck that deprived conservatives of a committed champion of their health-care vision. Republican candidates responded to what the public has demanded. Indeed, Romney’s experience creating the precursor to Obamacare, far from hurting him, provided the foundation for his best moment in the entire campaign. It came in the first presidential debate, when he cited his history as a guide to how he would act as president. (“I do have a plan that deals with people with preexisting conditions. That’s part of my health-care plan. And what we did in Massachusetts is a model for the nation state by state.”)
Conservatives cannot point to any real-world examples of a country or even a state that has successfully implemented the sort of health-care system they desire. (Some of them mistakenly cite Singapore, whose health-care system relies on massive state intervention American conservatives could never accept.) That’s because there’s no electorate in any industrialized country that would tolerate it.
Is that because a conservative health-care plan with catastrophic coverage and high deductibles is technically impossible to design? No, it’s because such a plan is politically impossible to sustain. People don’t want insurance coverage that only protects them against rare disasters. They want to be able to go to the doctor and get treated. In the English vernacular, comprehensive coverage is called “good insurance” and high-deductible insurance is called “bad insurance.”
Suppose we lived in a world in which Trump had decided to implement a true conservative health-care plan, and he persuaded Republicans in Congress to take the massive hit to their standing by passing one. What would happen next? Well, once it happened, and tens of millions of people were thrown into the individual market where they could only afford bad insurance, Democrats would start promising to give them good insurance instead. Eventually they would win and give it to them.
The Republican Party’s fanatical struggle against Obamacare gave conservative intellectuals a great deal of false hope. By pressuring members of Congress to withhold support in Congress, the Supreme Court to make the Medicaid expansion optional, governors to sabotage state exchanges and turn down the Medicaid expansion, and imposing uncertainty on insurers, they generated an atmosphere of maximum chaos and controversy around the law. They managed to create the impression that Obamacare was a dirty piece of business, and that it was responsible for every bad thing in the health-care system. But they never sold the public on the idea that Americans should not have access to basic medical care.