On Thursday, the Republican-held House of Representatives postponed its vote on the American Health Care Act, aka RyanCare, aka TrumpCare, because the leadership couldn't secure enough votes for it. President Trump has since delivered his congressional colleagues an ultimatum: Pass the AHCA on Friday, or live with ObamaCare.
The AHCA is probably dead. Even if it somehow passes the House, it will almost certainly not pass the Senate. Inevitably, this whole mess will be portrayed in the press as a humiliation for an administration whose leader touted his ability to get deals done. And obviously, this is not a good look for the White House. But whether they know it or not, Republicans dodged a bullet when the AHCA went down in flames.
Health care has been a winning political issue for Republicans for eight years. ObamaCare has had lots of problems, and in the minds of voters, Democrats "owned" health care. So anything bad was blamed on them, not just by die-hard Republicans, but also by swing voters. But today, the GOP, as the party that holds the White House and both houses of Congress, owns health care. Which means that anything bad that happens will be blamed on them.
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And under the AHCA, bad things would have happened. It was just a mess of a bill. Millions of people, especially Trump voters, would have lost coverage. Regulations that keep health-care costs high would have largely stayed in place because the Republican Party decided to pass the bill through a process known as reconciliation, which requires only 51 votes in the Senate but can only affect the parts of ObamaCare that directly affect the budget. The structure of the bill's tax credits, favoring older voters at the expense of the young, and the rich at the expense of the poor, was akin to a Democrat caricature of what a Republican health-care bill would look like. The attack ads just write themselves.
If the AHCA became law, it would have made a mess similar to the mess created by ObamaCare (and probably worse, suggests the CBO), except this time Republicans would own the mess. Which makes for a predictable result: losing a lot of elections. Especially when the hardest hit by the AHCA's regulations are white working-class voters who voted for Trump because they felt betrayed by the establishment.
So what should conservatives do?
This is a quandary where two conservative priorities are put in tension. Conservatives want to deregulate health care. And conservatives want the government to spend less money on health care. The problem is that they can't do both. If they repeal bad ObamaCare provisions (and they are bad), such as guaranteed issue (which forces insurers to provide coverage to anyone), or community rating (which prevents insurers to price based on the customer's actual risk), many people will suddenly find coverage unaffordable. If these people don't get money to compensate for those short-term fluctuations and keep getting covered, there will be millions of pissed-off Americans. By the same logic, if conservatives want the government to spend less money on health care, the only way to do it in the short term is through regulations that force insurers, and maybe providers, to provide services at essentially below cost, which means regulation. The AHCA tries to thread that needle by doing a little of both, but it won't work. It won't work politically, because it gives every stripe of conservative a reason to be angry; and it won't work on the policy merits, because lots of people will lose coverage and because it won't fundamentally inject consumer dynamics into the health-care system.
One of the deep and time-honored insights of conservatism is, quite simply, that you don't always get everything you want, because the world is tough. Conservatives are going to have to choose. And they should choose the approach that gets rid of the regulations.
The goal for conservatives in health care is to have a system where prices go down over time through consumer choice and innovation. That requires active consumers and a deregulated marketplace. In the short term, because of the way ObamaCare was designed, the only way to accomplish this without committing political suicide where 15 million sick people are suddenly dropped is to write some checks.
Slash regulations. And then subsidize health care. That has to be the conservative answer.
Obviously, that's just my point of view. But at least I have a point of view, something the Republican leadership has conspicuously failed to have. They have yet to truly evaluate different choices, realize that every path includes trade-offs, and make a decision. "It's time to lead" is one of the most tired clichés in American politics, but in this specific instance, never has it been more appropriate.
