I’ve occasionally been known to brag about one prediction that’s working out well: that Medicaid expansion under the Affordable Care Act would eventually be adopted by the entire nation. Although we’re not there’s yet, it’s on the way.
But I had another expectation that hasn’t worked out at all. By this point, I thought that the US would’ve returned to normal health-care politics. Republicans would push to reduce spending and coverage; Democrats, to expand both. Republicans would claim Democrats are overspending; Democrats would argue that Republicans are too cheap. Republicans would push to increase the market aspects of the system, while Democrats might, as former Vice President Joe Biden seeks to do, add more public aspects. But the basic structure would work well enough that, at least for a while, structural change would be off the table.
I was certainly wrong about that.
On the Democratic side, of course, the near-consensus from the 2008 campaign and the 2009 congressional debate collapsed in the 2016 presidential-nomination process, with Senator Bernie Sanders’s faction pushing to replace the ACA with a single-payer system. For now, at least, that’s still a minority position, and Medicare-for-All supporters haven’t won enough offices to make it the party’s policy.
But at least that’s a legitimate policy disagreement. The Republican side?
Instead of accepting the ACA, the party position is still to get rid of it. Well, technically, it’s to “repeal and replace” it, but 10 years after adopting that slogan there’s still no replacement plan that Republicans support. To say that this has caused problems is an understatement. In both the 2018 and 2020 elections, Democrats have made health care their lead policy issue; during confirmation hearings in the Senate this week, it was the main thing they wanted to talk about. While Republicans are still trying to have the entire law thrown out in court, they’re increasingly on the defensive about the issue.
President Donald Trump, meanwhile, has made everything worse. He has barely bothered to learn the vocabulary of health insurance, let alone any of the actual arguments at play. When challenged about it during an NBC town-hall program Thursday night, his argument was that “the problem with Obamacare, it’s not good.” His solution? “A much better health care.” This is not exactly inspiring rhetoric. Yet it’s really not much better than the typical congressional Republican talking points.
It’s not that conservative health-care reform is impossible; the journalist Philip Klein wrote a book about it a few years ago giving multiple options. One problem is that very few Republicans enter politics to deal with this issue; they tend to just not be very interested in it. A bigger problem is that the Republican Party at the national level just isn’t able to handle policy development these days.
One option, given all of that, would be to just move on. If Republicans stopped talking about Obamacare and trying to eliminate it, they’d make it a lot harder for Democrats to score points on health care. The party is capable of that; after President George W. Bush’s ill-fated effort to privatize Social Security, Republicans stopped talking about the issue (for the most part) and it lost its appeal to Democrats as an electoral weapon.
The thing is, there isn’t really a strong constituency within the party for actually repealing the ACA. What does appear to be true is that Obamacare-bashing is still a successful product within the conservative marketplace, and so Fox News and other partisan media keep talking about it. And where they lead, the party follows. That this is all a highly dysfunctional way for a political party to behave, at least if it hopes to govern well enough to keep getting re-elected, just doesn’t seem to enter into the discussion.