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You Got Nothing

Face it: Republicans are never coming up with a health care plan.

One of the things Republicans seem to have forgotten, in the wake of the introduction and swift passage of their Dickensian budget crafted by Paul Ryan, is their unshakeable commitment to health care reform. Remember that? Throughout the health care debate, they were determined to rally around their own reform plan. And now the House has passed a long-term budget that yanks health insurance away from more than 40 million Americans and neglects to put anything in its place. Maybe it’s just an oversight, like the time in freshman year when I turned in a history paper with no bibliography. But it’s kind of starting to look like the Republicans don’t actually plan to do anything for the uninsured.

The history of the elusive Republican quest for a health care plan dates back at least to 1993. President Clinton had proposed comprehensive reform; the public believed the system to be in crisis. Congressional Republicans came up with a combination of subsidies, market regulation, and an individual mandate that presaged the law eventually signed by President Obama last year.

But as the debate dragged on, Clinton’s plan sunk, and Republicans backed away from their proposal, insisting it was better to start fresh the next year. “We don’t have to do it all this year,” GOP Senate leader Bob Dole announced in 1994. “You know, Congress meets every year.” Republicans promptly took control of Congress but never managed to get around to reforming health care the next year or any of the dozen years in which they ran the place.

That’s where things stood until 2009 when, having regained first the Congress and then the White House, Democrats coalesced around a health care reform plan similar to the 1993 GOP version. Even though voters backed most of its specific elements, they opposed the plan itself. Yet the public considered the status quo totally unacceptable and overwhelmingly favored a sweeping overhaul. Even at the trough of support for reform, Americans, by a 30-point margin, wanted Congress to keep trying to pass a comprehensive plan.

And so, whenever Democrats accused Republicans of trying to deep-six the whole project, conservative lawmakers would respond with indignation at this vicious slur upon their reputation. It’s “ludicrous,” said one. “Completely untrue,” insisted another. Republicans earnestly claimed they wanted to “start over,” so as to expand coverage and control costs without forcing anybody to change anything. A few sad little gestures popped up in Congress, but nothing like a “Republican health care plan” ever emerged.

Taking control of Congress again this year, Republicans immediately set about undoing health care reform. Carefully following the advice of pollsters, however, they insisted their true goal was not to overturn the law but to “repeal and replace.” The effort began with a straight-up vote to repeal health care reform and replace it with, technically speaking, nothing whatsoever. But fear not! “Repeal is the first, not the last step,” wrote Ryan and four other Republican chairmen. “Compassionate, innovative and job-creating health care reform is what’s next.”

Alas, the race to discover this compassionate, innovative, job-creating health care plan has proceeded with all the urgency of O.J. Simpson’s search for the true murderer of his late wife and her paramour. The effort began with earnest proclamations of intent. Take, for instance, Representative Fred Upton, who, as chairman of the Energy and Commerce Committee, held the responsibility for crafting the long-promised legislation. “We recognize that there are reforms that are needed. We’re not going to just sit on our hands and do nothing,” he promised on January 17, two days before the repeal vote. Three days later, he averred, “We will use every tool at our disposal to dismantle this law and develop a better path forward.” That same day, he promised once more, “Today is day one of our effort to replace ObamaCare with something better, a lot better.”

Days two through 106 have passed with no sign of an alternative plan. Congress held hearings lambasting the Affordable Care Act, but made not even a token attempt to craft a substitute. Repeal-and-replace simply morphed into repeal-and-more-repeal.

By the time Ryan unveiled his budget, Republicans had discarded the “replace” pretense entirely. And so they voted for legislation that not only eliminated health insurance for the 30 million Americans covered under the Affordable Care Act, but hacked a staggering $771 billion out of Medicaid’s budget over the next decade, throwing millions more off the insurance rolls.

Was this perhaps some kind of short-term measure designed to clear out budget space for a future health care reform? Oh, no. Ryan didn’t even gesture toward setting aside any funding to cover the uninsured in a budget plan that claims to extend past 2050.

Conservatives adore Ryan’s budget perhaps because it liberates them from the exhausting burden of pretending to care about the uninsured. It begins with the assumption of perfect markets everywhere and dispatches any attempt to correct for market failures—by, say, covering the uninsured—in purely ideological terms. (Subsidizing insurance for those who can’t afford it leaves them “helplessly dependent on their government.”) Inside this snug little loop of reasoning, if the answer isn’t the free market, you’re asking the wrong question.

The truth is that Ryan lacks the courage to spell out his premises. In 2007, he opposed a modest bill to expand coverage to some uninsured children. “We need a more comprehensive fix,” he insisted. In 2010, he argued that comprehensiveness was the whole problem. “Let’s scrap this bill and start over,” he pleaded. “Let’s focus on step-by-step, common-sense reforms that lower health care costs.”

Neither Ryan nor his adoring fans will actually concede that they want to leave tens of millions of Americans uninsured, preferring to overlook the ugliness of the reality for the beauty of the abstract concept. Republican economist Douglas Holtz-Eakin exalted: “Under this plan, there is a vision of small, contained government that supports rapid economic growth, is fair to future generations, and restores America’s exceptionalism.” If Ryan gets his way, America, the sole advanced economy in which citizens who contract treatable illnesses routinely go bankrupt or die of neglect, would retain this exceptional status.

Jonathan Chait is a senior editor at The New Republic. This article originally ran in the May 26, 2011, issue of the magazine.

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