I believed the hype. At the beginning of this year I thought President Trump would sign a reconciliation bill gutting the Affordable Care Act (ACA) by the time Congress took their February recess, the GOP’s own set schedule.
They didn’t. It turned out the GOP’s policy intellectual class were the ones that needed catastrophic coverage, not the country, as the failure of their plan was so ultimate and total it still surprises me. It’s an amazing moment for our country. Health care is now the public’s responsibility. We build forward, and we aren’t going back. Everyone should learn some lessons, and here’s how I’m updating my thoughts so far.
This is the GOP’s Fault
This is not President Trump’s fault. A President Rubio or President Jeb! would have had the same exact problems with the same exact outcome. This was driven by Congress, and it derives from the initial strategy of “repeal and delay” collapsing immediately and the backup plan not being tested.
Don’t lose sight that the original plan was repeal the ACA’s funding with a two year delay to get their ducks in order and threaten the Democrats with a collapse of the health care markets. This is the reconciliation bill they sent to President Obama in 2016 and was the plan for this year as well. This is pure debt ceiling logic — threaten chaos over the entire economy to try and force concessions from your enemies and solidarity among your side — that didn’t work particularly well for the GOP with Obama in charge, and would have been lethal to them while they were in charge.
I didn’t expect the eventual bill to be a mess that appeased no one because I assumed there was a concrete bill. But, as Mark Schmitt notes in a righteously angry piece, “Despite years to prepare, repeal supporters did none of that work.” Instead it was meant to be developed over two years during the delay period. But that could never have been done without scaring too many people. Once they actually had to try to make a real plan there was no appetite for it. Perhaps Trump attacked the ACA too much from the left, but the GOP had been doing that for years. There was no plan, and the attempt to force one was dangerous and reckless.
I thought activism worked anyway. But I worried that, with polarization and geographic stratification, it would work less. The majorities in 2009 were much larger, but they were in many districts that leaned Republican and had centrist members. And Tea Party activism ultimately failed to stop the ACA from passing. Since then, hard ideological movement to the right and a massive funding network post-Citizens United had me worried that the Right would happily march off an electoral cliff to take away health care from millions of people.
Everyone is blaming the House Freedom Caucus, but as Matt Fuller notes the more notable event would have been the 30 moderate GOP members voting no if the vote had happened. Since the moderates chose not to support the bill, the GOP was forced to rely more on the hard-liners, who didn’t show up. Activists got to those moderates, and they got them by forcing them to accept continuity with the ACA, to acknowledge the coverage numbers mattered, and by getting them to defend Medicaid.
They did that by demonstrating how these programs benefited them. News coverage used to focus on people who didn’t like the ACA; suddenly we got to see the stories of people who depend on it, the people whose lives were saved. It made the benefits far clearer than they had been before, and made it harder to go back.
Hell yeah it does. I already thought this but it is humbling to see the concept reveal its awesome power.
I assumed no matter what else happened with the exchanges, Medicaid was going to get trashed. Gene Sperling was warning out the door about Medicaid’s vulnerabilities, and the federal-state combo made it easy to do funding cuts that obscured their savagery of those changes. When I learned how Medicaid cuts would be turned into a first round of high-end tax cuts, ones that would prime the pump for permanent high-end tax cuts later, I thought it was in even more trouble. Before the election I even wrote that the targeted universal nature of the Medicaid expansion wouldn’t be enough to get people to defend it.
I was wrong, and the expansion of the program to people above poverty saved it. We need more work on this dynamic, but it looks like the merging of an anti-poverty program to a broader security measure for working class people triggers several defensive mechanisms. One is that it creates a broader coalition of defense, groups that might be bitterly opposed in many other ways but have a united interest in saving this program. Two is that it is transformed away from a “poor program for poor people” to a broader program in the popular imagination, one that becomes easier for the political class to defend. That’s unfair it has to come to that to get defense, but life is unfair. Another is that more influential, institutional networks are created around and rely on Medicaid as it is expanded, causing the defensive mechanism Paul Pierson identified as halting the process of retrenchment. Clearly, the Republicans weren’t ready to go to war with Republican governors over starving their states and their medical constituencies of health care funding.
Wonks Get Lost in Their Echo Chambers
I don’t do health care, but like many others I was obsessed with it in past months, reading everything I could find. It’s crazy to come into an argument that’s already going, and seeing conservatives who were supposed to be the intellectuals convince themselves of the most absurd statements. Take this, from AEI’s “Improving Health and Health Care: An Agenda for Reform,” a defining statement by 10 policy writers:
The central focus of the ACA and, in fact, the central focus of many health care reform efforts has been to decrease the number of Americans without health insurance protection. […] But this near-exclusive focus on health insurance is also ironic because, in truth, consumers generally are not all that interested in health insurance. What they care about is better health and access to care. […] that means promotion of more direct and more flexible methods for purchasing services [like health savings accounts].
What has happened where you have “in truth, consumers generally are not all that interested in health insurance” as a defining health care statement that you use to guide the entire Republican establishment? From the sensible observation that bad insurance isn’t worth very much, they take the lesson that insurance itself doesn’t matter and people are indifferent between having insurance and self-funding health savings accounts.
Was this meant to tell the GOP that they can ignore a bad CBO analysis? I can tell you that out in the real world people are very sensitive to whether they have insurance, and programs designed to be tax giveaways to the professional class don’t make up the difference.
How did Republicans end up in this position where ideas that should function as a railing and guide end up speaking to nobody? McKay Coppins wrote that recent changes have led to “a caucus full of conservatives with excellent ratings from the Heritage Foundation, and no idea how to whip a vote” in Congress. The DC conservative policy apparatus has followed a similar path. It have also become accountable only to itself, ideological donors, polarizing media, and a race against their own extreme instincts. It’s the dynamic David Frum diagnosed in his classic Waterloo essay, but among the intellectual class as well.
So I’m taking the advice to make sure I never get too lost in my own cleverness and esoteric debates like the Right has. The goal is to address the needs of real people fighting on the ground with useful solutions, not parlor games with other ideologues. That’s good advice for us all.