The implosion of the Republican health-care bill has to count as one of the most spectacular legislative failures in years, since at least Bill Clinton's attempt to reform health care died in 1994, and maybe longer. Why was it such a mess, ending in such a humiliating defeat? There are many reasons, including the intractable disagreements within the Republican Party and the simple fact that Americans didn't want to buy what they were selling.
But I want to focus on one critical source of the failure: Republicans never cared about health care in the first place. That indifference produced a cascade of problems and pathologies that made their defeat all but inevitable.
Over the years since Barack Obama became president and made health-care reform one of his first priorities, I've had conversations about this question with numerous conservatives, and not one of them challenged this assertion when I made it. Republicans care a lot about taxes, and the military, and other issues, but for all but a few of them, health care just isn't their thing. It doesn't animate them or fascinate them. The issue was forced on them as a political matter by the Affordable Care Act, but even then they never cared all that much about the substance of it. Yes, there are politicians like Paul Ryan who dream of eviscerating Medicaid and privatizing Medicare, but it's because they want to scale back government, not because they're concerned with the mechanics of health-care delivery.
To be clear, that doesn't mean there aren't a few serious Republican health policy wonks, because there are. But that isn't enough. If you're going to undertake a massively disruptive policy change like the one Republicans just attempted, you need the entire party to engage with both the substance and the politics of the issue. That's the only way to get a sufficient consensus around the plan you eventually arrive at.
Democrats do care deeply about health care, and so they spent years talking about it, thinking about it, coming up with plans they mulled over and criticized and tried to improve. So when they actually got the opportunity to pass something when Obama was elected, the party had worked through its differences to the point where everyone was willing to rally around a single approach, even if it might not have been completely to their liking.
That's a critical and often overlooked element in the policy process: not just everyone figuring out what they want, but figuring out what they don't really want but they can live with. For instance, liberals were unhappy with the fact that the ACA didn't include a public option for people on the individual market to buy into a government plan like Medicare or Medicaid. They also had misgivings about the fact that the bill relied so heavily on the private market. But they had come to accept that given the political constraints, the ACA was about the best they were going to get at that particular moment, and the opportunity couldn't be squandered. They kept trying to change it until the end, and those on the party's right flank held out to make the bill as conservative as they could — the argument went on right up until the roll was called. But they all voted for it, and they didn't have a single vote to spare.
Republicans never had the stomach to go through that process, the lengthy and painful gestation and birthing of their bill. If they had, they would have confronted a fundamental challenge, one that goes like this: We have a set of ideological and policy preferences. But the majority of the public might not share them. So what do we do? We can try to persuade the public to change its mind, but that's very difficult. Or we can figure out how far we'd need to move to the center to produce a bill the public will support — and decide if we've gone so far that we can't live with the compromise. That might even involve changing our own preferences, or seeing this period not as the entire battle over this issue, but as one phase in a process that might take years or even decades to unfold completely.
Republicans weren't willing to invest the time and energy in that process, instead thinking they could do it on the cheap. They could just attack ObamaCare without bothering to have in place their own plan, assuming they'd be able to throw it together if it ever became necessary. Very few of them took the time to understand health-care policy in depth, so they weren't prepared to grapple with the choices they'd have to make when it came time to write their bill. They made promises they should have known they could never keep: Your deductibles will go down (even though their plans promote higher deductibles), your premiums will go down, we'll banish narrow provider networks (something the government doesn't control and that insurers began using before the ACA came along), more people will get insurance, it'll be perfect and wonderful. President Trump's ridiculous assertion that the ACA could just be tossed out and replaced with "something terrific" was only a slight exaggeration of what most Republicans were saying.
And though they might not want to say it out loud, right now there are more than a few Republicans who are feeling relief. Yes, this has been a political disaster, and they'll have to answer to base voters disgusted that they couldn't come through on a promise they've been making for the last seven years. But now that they can move on to slashing the safety net, increasing military spending, and cutting taxes, at least they won't have to pretend to care about health care anymore.
Until, that is, Democrats take power again and begin to promote some version of single payer. Then Republicans will be dragged back in to the issue all over again.