A Bill with No Governing Philosophy

House Republicans have released their proposed measure to “repeal and replace” Obamacare, and the whole enterprise is already losing steam right out of the gate. The measure is too small and incremental, less a repeal of Obamacare and more of a repair of it, keeping numerous basic features intact.

If you want to know why Republicans have bogged down, notice one peculiar thing about the Obamacare debate so far. It’s not really a debate over Obamacare, it’s a debate over Medicaid. The reason is that this is what Obamacare mostly turned out to be: a big expansion of Medicaid. The health insurance exchanges that were supposed to provide affordable private health insurance (under a government aegis) never really delivered. They were launched in a state of chaos and incompetence, and they ended up mostly offering plans that are expensive yet still have high deductibles. Rather than massively expanding the number of people with private insurance, a lot of the effect of Obamacare was to wreck people’s existing health care plans and push them into new exchange plans.

Ah, but what about all those people the Democrats are claiming were newly covered under Obamacare? A lot of them—up to two-thirds, by some estimates—are people who were made newly eligible for a government health-care entitlement, Medicaid. But shoving people onto Medicaid is not exactly a great achievement, since it is widely acknowledged to be a lousy program. Conservative health care wonk Avik Roy explains why: “[T]he program’s dysfunctional 1965 design makes it impossible for states to manage their Medicaid budgets without ratcheting down what they pay doctors to care for Medicaid enrollees. That, in turn, has led many doctors to stop accepting Medicaid patients, such that Medicaid enrollees don’t get the care they need.” Partly as a result, a test in Oregon found no difference in health outcomes between those with access to Medicaid and those without.

Then again, a massive expansion of Medicaid fits perfectly with the preferences of the welfare statist’s boosters: lousy free stuff from the government is better than good stuff you pay for yourself.

And yet, notice that this hits a big Republican weak spot, one I suspect Obamacare’s promoters knew about all along. ObamaCare just boils down to an expansion of an old, existing, traditional government entitlement—and Republicans are lousy at rolling back traditional entitlements.

For those who blame Paul Ryan for this, by the way, it’s worth remembering the main reason anyone was ever excited about Paul Ryan in the first place: he was the first politician to put forward plans to reform middle-class entitlements, and the most amazing part is that lightning did not strike him dead and the earth did not swallow him up. He touched “the third rail of American politics” and survived. He was The Boy Who Lived.

Unfortunately, Ryan is billing the House’s Obamacare replacement in precisely those terms: as “entitlement reform.” He isn’t aiming to roll back a giant new entitlement. He’s aiming to tinker with it and make it better. He’s still accepting the one-way ratchet of American politics: Democrats create new entitlements, then Republicans reform them. Democrats get all the credit for showering us with benefits, and Republicans accept the role of the mean-spirited accountants who tell us we just can’t afford it.

The whole point of repealing Obamacare, as some of us have been arguing, was to break that cycle, to show Democrats they dare not risk losing seats in Congress to push through a big new program, because it can all get dismantled the moment Republicans are back in power. I wish I could say I’m surprised we didn’t break that cycle. The Republicans can be good at playing defense, holding the line against new government expansions that temporarily shock the sensibilities of their voting base. But the base eventually moves on to the next big outrage (“illegal immigrants!”), and the politicians lose the initiative to go on offense in favor of an opposite ideological approach.

I would be more bitter about the role of the House Republicans—who had seemed to turn noticeably to the right since the passage of Obamacare—except that in this case, the Republican Party establishment is not really lagging behind the Republican base. The base has recently proved they don’t care all that much about rolling back the welfare state, because they elected, in the primaries and in the general election, a politician whose agenda has never included a rollback of the welfare state. Donald Trump was clear on that about Social Security, and he was particularly clear when it came to health care, where he declared his plan for something that was a lot like Obamacare but would supposedly work better. That’s pretty much what the House Republicans just delivered for him.

Pradheep Shanker sums it up nicely when he describes the Obamacare replacement bill as a piece of legislation with no ideological point of view.

My biggest complaint about this bill is that there really is no governing philosophy in its writing. It neither pleases conservatives nor moderates. It makes half measures to increasing patient choice, but retains taxes such as the Cadillac tax, while at the same time maintaining the employer based health insurance system. It doesn’t maximize federal support for the poor, nor does it fully adopt the free market…. The muddle created by the GOP here makes it very difficult to make a sound, concise argument regarding specifically what their goal is.

That makes sense, in a way. It’s a bill with no governing philosophy for a party and a president who have no governing philosophy.

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