If Republican leadership had told conservatives in 2013 that they could pass a bill that would eliminate the individual and employer mandates, phase out Obamacare’s Medicaid expansion, cut an array of taxes, and lay out the conditions for full repeal later, I imagine most would have said “Sign me up!” Especially if they contemplated the only other viable option: ziltch.
That’s the choice now. Majority Leader Mitch McConnell has finally revealed the specifics of Republicans’ “secret” health-care bill — “Better Care” — and, reportedly, he wants a vote by next week. Senators Rand Paul, Ted Cruz, Ron Johnson, and Mike Lee all say they will oppose the bill as written. There’s a chance they’ll be joined by some moderates who feel reluctant to trim Medicaid. At this point, it feels like most of them want to get to yes and are posturing for concessions.
Or maybe the entire debate is a giant kabuki dance for voters, and nothing will pass.
Whatever the case, Republicans should ask themselves what the alternative looks like. Listen, I wish Mike Lee were writing a market-based Obamacare repeal bill and that we had a president who was interested in reforming welfare, but at some point conservatives are going to have to take a page from Democrats and occasionally embrace incrementalism. Idealism is empowering and necessary. Yet pragmatism can’t always be treated as a transgression. You’re going to see the bill change — provisions in the bill might need to be altered once we get a Congressional Budget Office score and the parliamentarian vets it — but you’re not going to see a market-based iteration of reform. It’s going to have to be achieved piecemeal.
If the House couldn’t cobble together a genuine repeal, there is little chance that senators who have to go home to statewide electorates would be in a position to do so. In fact, it’s surprisingly “conservative.” For one thing, voters like parts of Obamacare—forcing coverage of preexisting conditions, for instance—that make a full repeal impossible. For another, some senators simply won’t sign on to immediate Medicaid rollbacks.
The Obamacare debate was also an intramural affair, crafted to allay the concerns of moderate Democrats, not Republicans. What Democrats correctly understood was that they were engaged in a war of attrition. Even the Affordable Care Act (ACA), until very recently the most unpopular major reform in American history, is astoundingly difficult to repeal.
So it is what it is. Or, rather, it is what McConnell says it is. In 2013, Dan Foster wrote about McConnell’s preternatural ability to push the debate as far right as it’s willing to bend:
[I]f you ever want to know where to find the rightward-most, feasible position for Republicans to take in a given political crisis — and as the president is wont to point out, there’s a new one every week — look for Mitch McConnell. He’s usually sitting there in a folding chair, waiting for everybody else to show up. McConnell’s disposition on a given issue can be either heartening (e.g., on what would prove to be the last extension of the Bush tax cuts) or disheartening (e.g., on the debt-ceiling) but it almost always represents the right flank of the politically possible.
Whether you like McConnell’s disposition is another story. Is this bill near the political sweet spot? Probably.
Many people I respect argue that passing half measures would preserve rather than dismantle Obamacare’s most corrosive mechanisms over the long run. I’m also skeptical that any major rollback of Medicaid expansion will come to fruition in 2020. But setting up this debate matters. That’s because, despite their recent string of wins, Republicans have no clue what the political environment will look like next year. This might be the last chance to do anything. If it’s not the last chance, they can always build on a bill they have passed.
Speaking of political environments: can the GOP really afford to pass up this opportunity? Obamacare repeal was one of the most potent political issues in decades. From the day the ACA was passed to the day Donald Trump was elected president, Republicans picked up around 1,000 seats. The most pervasive issue in all those campaigns was the persistent failures of Barack Obama’s signature achievement. The idea the GOP can take both houses and the presidency then avoid it would be political malpractice on a historic scale.
Meanwhile, it’s also worth remembering that no matter what the Republican bill evolves into, no matter how moderate or extreme, the over-the-top scaremongery rhetoric of liberals and most of the media will be identical to what you hear now.
To some extent people are immune to the drama. No, that doesn’t mean the Republican bill is popular. Likely no reform will poll well at this point. Voters tend to treat health care policy holistically, concluding that whatever problems they face must be the fault of whomever is in charge. By being in power, GOP also owns health care. To some extent, this was true of Obamacare, as well.
It’s worth reminding Americans that their premiums have skyrocketed, that Obamacare’s fabricated exchanges have given them fewer choices and higher prices (they are in the midst of collapsing), and that Democrats basically foisted a poorly functioning welfare program on everyone. But if Republicans truly believe they have something better, they need to start making compelling arguments for why. Otherwise, none of this will matter.