When congressional Republicans pulled the American Health Care Act from the House floor last Friday, Philip Klein let it rip. The Washington Examiner’s managing editor tweeted that the demise of the GOP’s Obamacare alternative was a “massive embarrassment” for President Donald Trump. A few hours later, Klein fired off a devastating column calling it “the biggest broken promise in political history,” adding that “this episode shows that Trump and the GOP are perfect together—limited in attention span, all about big talk and identity politics, but uninterested in substance.”
“Failing to get the votes on one particular bill is one thing,” he wrote. “But failing and then walking away on seven years of promises is a pathetic abdication of duty. The Republican Party is a party without a purpose.”
Klein was right to be angry. A leading health care policy expert on the right, and the author of the 2015 book Overcoming Obamacare: Three Approaches to Reversing the Government Takeover of Health Care, he had spent years urging Republicans to find a consensus conservative replacement for the law—practically begging them to get down to the details. And last week, he watched the party implode in exactly the way he’d predicted: Undone by internal strife and a fundamental failure to think through policy specifics.
“It’s incredibly frustrating,” Klein told me this week. “I mean, I don’t want to get into an Oprah thing and make it about me and how I feel, but obviously it’s frustrating.”
For conservative health care wonks, the failure of the American Health Care Act wasn’t just a missed opportunity or a broken campaign promise or a political defeat. It was proof that the Republican Party’s seven-year pledge to replace Obamacare was almost entirely a political gambit.
According to Avik Roy, a reform-minded conservative and the president of the Foundation for Research on Equal Opportunity, “most conservatives didn’t think there was a moral case for replacing Obamacare” and accepted the idea only as a political imperative to avoid the consequences of completely abandoning the uninsured.
In the end, the GOP couldn’t get the politics right to pass Trumpcare, but the blame cannot be pinned on Republican moderates or extremists. The entire party owns this failure because ultimately it was caused not by political divisions, but policy apathy.
“Consistently,” Klein said, “there’s been a long-running problem that a lot of Republicans don’t care enough about health care policy.” Michael Cannon, the director of health policy studies at the libertarian Cato Institute, was more emphatic: “Republicans don’t care about health policy.”
Before President Barack Obama signed the Affordable Care Act into law, Democrats deliberated on the legislation for over a year—carefully consulting with experts, including those who’d worked on former Massachusetts Governor Mitt Romney’s successful health care overhaul. The bill’s drafting certainly had its share of political considerations—a proposed public option was defeated, as was an amendment banning coverage of abortions—but as Klein acknowledged in his column, it was a comprehensive policy process:
They spent 13 months getting the bill from an initial concept to final passage, and pressed on during many points when everybody was predicting doom. They had public hearings, multiple drafts of different bills, they kept negotiating, even worked into Christmas. They made significant changes at times, but also never lost sight of their key goals. They didn’t back down in the face of angry town halls and after losing their filibuster-proof majority, and many members cast votes that they knew risked their political careers. Obama himself was a leader, who consistently made it clear that he was not going to walk away. He did countless rallies, meetings, speeches — even a “summit” at the Blair House — to try to sell the bill, talking about details, responding to criticisms of the bill to the point that he was mocked by conservatives for talking so much about healthcare.
Klein thinks Trump and the Republicans should have done the same with the AHCA. “To repeal and replace Obamacare in what I would consider the right way,” he said, “you’re probably talking about a year, and you’re probably talking about significant loses in congressional races.”
House Speaker Paul Ryan and his fellow Republican leaders weren’t willing to do that. “The most galling aspect of the AHCA was the process itself, in which House GOP leaders recklessly put haste and politics above good policy,” Roy wrote in National Review this week. He criticized the hurried pace—18 days from the release of the draft bill to the day it was voted on—which prevented many lawmakers from contributing or even drafting amendments. “It was too fast of a process,” Roy told me. “There had been no effort to build consensus or even a moral case for the legislation, and the policies were deeply flawed in many ways.”
The lack of support for the AHCA among policy-minded conservatives can’t be overstated. Earlier this month, Vox’s Ezra Klein noted, “Experts from all three of Washington’s major conservative think tanks—the American Enterprise Institute, the Heritage Foundation, and the Cato Institute—oppose it.” Cato’s Cannon told me, “This bill looks like it was written by a stereotypical Republican who cares more about tax cuts than health policy.” He added, “Health care has never been a Republican issue. They focus on issues where they get more traction, like tax cuts and guns.”
The GOP ceded the health care issue to Democrats long ago, according to Klein. He said Republicans should have begun prioritizing conservative alternatives to Democratic proposals back in the 1990s, when the Clinton administration advanced its plans. When the Republicans did no such thing—not even during President George W. Bush’s administration—they let Democrats fill the vacuum. Again, after the Affordable Care Act took effect under Obama, the GOP was uninterested in developing a clear alternative.
“You could always unite Republicans around attacking Obamacare for having high premiums,” Klein said. “Trying to come up with different ideas to lower premiums creates problems in the caucus.” Part of the problem, he added, is that traditional Republicans see the entire discussion as the purview of the left: “The sense is that health care policy, when it’s being discussed, is all about what the Democrats want to do to turn us into Europe and a socialized system.”
According to Roy, this is precisely why Republicans were lukewarm on replacing Obamacare all along—many of them didn’t genuinely believe the federal government had a role in ensuring Americans were insured. He’s trying to change that thinking. “There is a moral case for covering the uninsured,” he said, “because it’s 70 years of federal policy that made health care unaffordable for people in America. To shrug our shoulders and say ‘tough luck’ to the people who can’t afford health insurance is wrong. It’s the federal government that’s created the problem in the first place. We have an affirmative duty as conservatives to tackle this problem. We should try to do it in a more market-oriented way, but we should try to tackle this problem.”
Roy has written his own plan for near-universal health care coverage. He believes the divide between conservative hardliners and moderates over the AHCA could have been bridged by combining regulatory reform with a means-tested tax credit program allowing assistance for low-income Americans. “That’s a way of getting both the centrist Republicans and right-wing Republicans on the same page,” he told me. “Centrists are very concerned about the coverage problem. The coverage problem can be fixed by a more means-tested approach. The conservatives or right-wingers are very concerned about regulatory reform, and you can actually achieve a lot more regulatory reform through a means-tested tax credit.”
Cannon, though, cast the hardliners as the only ones standing up for conservative health care policy. In a Monday column for CNN, he applauded the Freedom Caucus for opposing the AHCA, which he derided as the “Obamacare Preservation Act” for retaining “the very worst provisions of the law, including its so-called pre-existing conditions provisions...Keeping Obamacare’s regulations inevitably leads to keeping the rest of Obamacare, too. The only winning move is not to play that game.”
But Cannon and others don’t believe the game is over. “No matter what President Trump says, he is not done with Obamacare,” he wrote. “Congress still needs to rescue Americans from this law. Now they have a chance—and a responsibility—to do it right.” Roy also evinced optimism that the failure of the AHCA might now lead to a more constructive process on the Hill. “I think actually the political will has increased, because I think a lot of the people who said no to the AHCA feel an obligation to think hard about what they’re for,” he said, adding that it’s “healthy for those who disagree with you to try their idea out, find out it doesn’t work, and then there’s more openness to a different approach.”
But some believe new legislation will require Democratic buy-in. Robert Laszewski, another prominent Republican health care analysis, argued on Friday that “it is clear that an Obamacare fix cannot be negotiated with hard-line Republican conservatives,” and that “Trump and the Congressional Republican leadership would have a much easier time working with the Democrats—with whom they have more in common.”
The Democrats are only slightly more open to that idea than House Speaker Paul Ryan, who said on Thursday, “I don’t want that to happen.” Senate Majority Leader Mitch McConnell believes reviving Trumpcare would be futile. Trump, meanwhile, has sent mixed messages this week. On Thursday, he essentially declared war on hardline conservatives, tweeting that the “Freedom Caucus will hurt the entire Republican agenda.” But the day prior, according to The New York Times, the White House “invited two dozen leaders from conservative groups for a closed-door session to plot a path ahead. Participants...described the hourlong session as a welcome but long overdue policy discussion. It included a candid, polite airing of complaints that they have been largely left out of the loop on major administration decision making.”
Klein is skeptical that anything will get done on health care this year.
“I think the more interesting scenario becomes if Democrats take over Congress in 2018,” he said. “Does President Trump decide to cut a deal with them to move things further to the left? Maybe introduce a public option? That’s where things get interesting.”