Conservatives and the effort to "repeal and replace" Obamacare
One of the tasks Republicans have set for themselves since winning the presidency and retaining control of both houses of Congress in the 2016 election is to "repeal and replace" Obamacare. It's proven much more difficult than, to be completely honest, I expected. But mainstream coverage of the debacle has left me without a real way to understand the divisions among conservatives that have bedeviled the effort.1 Indeed, recent coverage left me with an impression that this amounted to a conflict between those who basically feel that Medicaid should not exist and those from states which adopted the Medicaid expansion that Obamacare offered or which face opioid addiction crises2 and whose residents would lose coverage.
Fortunately, it turns out that last February, Alice Rivlin did the yeoman work of picking apart conservative differences on the issue. She identifies a number of policy positions3 that help me to relate all this to the conservative tendencies I identified in my dissertation work. As Rivlin explains it,
The main problem is that Republicans are a diverse bunch who opposed Obamacare for a variety of reasons. Those most focused on shrinking the size and reach of the federal government thought Washington was already too involved in health care and should pull back, not expand its role or raise taxes to pay for new health spending. Those preoccupied with personal freedom balked at being required to buy health insurance. Others thought the widespread use of insurance to fund health care was already driving health spending too high and objected to further expanding health insurance. Still, others thought broadening health coverage was a desirable goal, but that the subsidies and regulations that Obamacare used to accomplish this goal were poorly designed and transferred too much power from the states to Washington. All of these Republicans could agree on trashing Obamacare, but they did not have a common intellectual basis for designing a replacement and they still don’t.4
Let's pick this apart. First, while I've argued that Obamacare essentially amounted to an unneeded bailout for the health insurance and pharmaceutical industries that fell far short of what (single-payer) is needed,5 one thing it does seem to have accomplished is expose a widespread belief that healthcare is a human right. Small government conservatives, that is, capitalist libertarians, paleoconservatives, and traditionalist conservatives, generally oppose the notion of human rights (they prefer 'natural rights' which are a whole 'nother topic) because the very fact of their existence requires government to protect and ensure those rights. Small government conservatives will seek to push back on any expansion of human rights. They also tend to favor less centralized power vested in local and state governments.
The 'personal freedom' argument is basically capitalist libertarian, but adopted by authoritarian populists and others espousing an intensively individualist conservatism. This argument will not necessarily be opposed by, but also not really endorsed by traditionalist conservatives or paleoconservatives. Traditionalist conservatives and paleoconservatives espouse a more 'communitarian' outlook (and you just might not agree with how they define 'community').
The final argument is the most interesting. The notion that insurance is part of the problem rather than the solution is difficult to categorize. In a way, it deploys the cost containment advantages of 'socialized' medicine against insurance companies and thus would seem to favor a single payer system. But first, anyone who has ever had difficulty getting an insurance provider to accept a claim for a needed procedure will doubt that there are any deficiencies in company efforts to control costs. Second, anyone who advances this argument is effectively admitting that market forces have failed to solve this problem—such an admission would be heresy for capitalist libertarians and neoliberals (and, therefore, neoconservatives). Finally, their recommended alternative, health savings accounts (which would be endorsed by capitalist libertarians), would only be achievable for the well off and would fail to address any urgent health needs that arise before a patient has accumulated the needed savings.
All of these arguments will run afoul of functionalist (so-called 'moderate') conservatives simply worrying about governing and staying in office. They're the ones who are tongue-tied at town halls when constituents demand to know why the government is taking away their healthcare and who face overwhelming opioid epidemics. And what the Republican leadership seemingly fails to recognize is that these functionalists are effectively admitting that they need to keep Obamacare even if they think it needs to be tinkered with.
- 1. Stephanie Armour and Kristina Peterson, "House GOP Health Bill Would Add 23 Million Uninsured, Cut $119 Billion in Deficit Through 2026, CBO Says," Wall Street Journal, May 25, 2017, https://www.wsj.com/articles/house-gop-health-bill-would-add-23-million-uninsured-cut-119-billion-in-deficit-by-2026-cbo-says-1495658914; Rachael Bade, John Bresnahan, and Kyle Cheney, "GOP faces make-or-break moment on Obamacare repeal," Politico, April 30, 2017, http://www.politico.com/story/2017/04/30/ryan-obamacare-repeal-house-republicans-237815; Rachael Bade, Kyle Cheney, and John Bresnahan, "Outlook for Obamacare repeal turns bleak," Politico, May 2, 2017, http://www.politico.com/story/2017/05/02/republicans-obamacare-repeal-votes-237871; Brian Bennett, "After the GOP healthcare bill fizzles, Trump blames the Democrats and says he 'learned a lot about loyalty,'" Los Angeles Times, March 24, 2017, http://www.latimes.com/politics/washington/la-na-essential-washington-updates-house-again-postpones-obamacare-vote-1490376174-htmlstory.html; John T. Bennett, "Trump Ready to Fight House Freedom Caucus," Congressional Quarterly Roll Call, March 30, 2017, http://www.rollcall.com/news/70187-2; Alexander Bolton, "In Senate, pessimism over ObamaCare repeal," Hill, May 4, 2017, http://thehill.com/homenews/senate/331842-in-senate-pessimism-over-obamacare-repeal (link is external); Alexander Bolton, "Senate GOP vows big changes for ObamaCare bill," Hill, May 5, 2017, http://thehill.com/homenews/senate/332025-senate-gop-vows-big-changes-for-obamacare-bill; Alexander Bolton, "Senate returns more pessimistic than ever on healthcare," Hill, June 5, 2017, http://thehill.com/homenews/senate/336145-senate-returns-more-pessimistic-than-ever-on-healthcare; Kyle Cheney and Rachael Bade, "Freedom Caucus holds fire on Senate Obamacare repeal bill," Politico, June 25, 2017, http://www.politico.com/story/2017/06/25/freedom-caucus-senate-health-care-bill-239919; Stephen Collinson, Dana Bash, Phil Mattingly, Deirdre Walsh, Lauren Fox, and M. J. Lee, "House Republicans pull health care bill," CNN, March 24, 2017, http://www.cnn.com/2017/03/24/politics/house-health-care-vote/index.html; Lauren Fox, "GOP on verge of losing health care vote," CNN, May 1, 2017, http://www.cnn.com/2017/05/01/politics/republicans-continue-to-work-on-health-care/index.html; Jessie Hellmann, "GOP struggles to find ObamaCare repeal votes," Hill, May 1, 2017, http://thehill.com/policy/healthcare/331478-gop-struggles-to-find-obamacare-repeal-votes; Siobhan Hughes and Kristina Peterson, "GOP House Leaders Pull Their Health Bill," Wall Street Journal, March 24, 2017, https://www.wsj.com/articles/gop-postpones-house-vote-on-health-bill-1490384577; Lisa Mascaro, "House GOP gives up on healthcare bill as Trump suffers first legislative defeat," Los Angeles Times, March 24, 2012, http://www.latimes.com/politics/washington/la-na-essential-washington-updates-house-again-postpones-obamacare-vote-1490376174-htmlstory.html; Seung Min Kim and Burgess Everett, "GOP senators not so keen on House's Obamacare repeal," Politico, April 27, 2017, http://www.politico.com/story/2017/04/27/senate-republicans-obamacare-repeal-237656; Lindsey McPherson, "Paul Ryan Concedes on Health Care, Says House Will Move On," Congressional Quarterly Roll Call, March 24, 2017, http://www.rollcall.com/news/politics/ryan-concedes-on-health-care-says-house-will-move-on; Kristina Peterson and Stephanie Armour, "GOP’s Health-Bill Woes Show New Power of Party’s Centrist Wing," Wall Street Journal, May 2, 2017, https://www.wsj.com/articles/gop-losing-votes-on-health-bill-imperiling-its-chances-1493742778; Andrew Prokop, "Paul Ryan just canceled the House health bill vote in a major defeat for President Trump," Vox, March 24, 2017, http://www.vox.com/2017/3/24/15014202/house-ahca-vote-canceled-trump; Manu Raju, Phil Mattingly, and Ashley Killough, "McConnell delays vote on health care bill until after July 4 recess," CNN, June 27, 2017, http://www.cnn.com/2017/06/27/politics/republican-health-care-bill-vote-delayed/index.html; Rachel Roubein, Peter Sullivan, and Jessie Hellmann, "Senate GOP delays ObamaCare repeal vote past recess," Hill, June 27, 2017, http://thehill.com/policy/healthcare/339682-senate-gop-punts-obamacare-repeal-past-recess; Nate Silver, "Why It’s So Hard For The GOP To Agree On Health Care," FiveThirtyEight, March 7, 2017, https://fivethirtyeight.com/features/why-its-so-hard-for-the-gop-to-agree-on-health-care/; Kelsey Snell, Sean Sullivan, and Mike DeBonis, "White House tries to salvage GOP health-care proposal as criticism mounts," Washington Post, March 14, 2017, https://www.washingtonpost.com/powerpost/conservative-lawmakers-continue-to-push-back-on-obamacare-plan/2017/03/14/f7331e70-08aa-11e7-93dc-00f9bdd74ed1_story.html; Peter Sullivan, "Power struggle over ObamaCare repeal," Hill, March 11, 2017, http://thehill.com/policy/healthcare/323491-power-struggle-over-obamacare-repeal; Peter Sullivan, "New CBO score triggers backlash," Hill, May 24, 2017, http://thehill.com/policy/healthcare/335058-new-cbo-score-triggers-backlash; Peter Sullivan, "Fifth GOP senator announces opposition to healthcare bill," Hill, June 23, 2017, http://thehill.com/homenews/senate/339206-fifth-gop-senator-announces-opposition-to-obamacare-repeal-bill; Peter Sullivan, "New CBO analysis imperils GOP ObamaCare repeal," Hill, June 26, 2017, http://thehill.com/policy/healthcare/339573-new-cbo-analysis-imperils-gop-obamacare-repeal; Peter Sullivan, "CBO: Senate ObamaCare repeal would leave 22M more uninsured," Hill, June 26, 2017, http://thehill.com/policy/healthcare/339534-cbo-22m-more-uninsured-with-senate-obamacare-bill; Peter Sullivan and Jessie Hellmann, "GOP bill hung up on pre-existing conditions," Hill, May 2, 2017, http://thehill.com/policy/healthcare/331632-gop-bill-hung-up-on-pre-existing-conditions; Peter Sullivan and Scott Wong, "GOP centrists push back on ObamaCare repeal," Hill, April 13, 2017, http://thehill.com/policy/healthcare/328769-gop-centrists-push-back-on-obamacare-repeal; Scott Wong, "Trump threatens to leave ObamaCare in place if repeal bill fails," Hill, March 23, 2017, http://thehill.com/policy/healthcare/325568-trump-tells-gop-to-take-it-or-leave-it-on-obamacare-repeal; Scott Wong, "Republicans won't vote on ObamaCare repeal bill this week," Hill, April 27, 2017, http://thehill.com/homenews/house/331018-republicans-wont-vote-on-obamacare-repeal-bill-this-week;
- 2. Rachel Roubein, "Opioid crisis threatens GOP ObamaCare repeal," Hill, June 24, 2017, http://thehill.com/policy/healthcare/339237-opioid-crisis-threatens-gop-obamacare-repeal (link is external)
- 3. Alice M. Rivlin, "Why Is It so Hard for Republicans to Replace Obamacare?" Real Clear Health, February 9, 2017, http://www.realclearhealth.com/articles/2017/02/09/why_is_it_so_hard_for_republicans_to_replace_obamacare_110432.html
- 4. Alice M. Rivlin, "Why Is It so Hard for Republicans to Replace Obamacare?" Real Clear Health, February 9, 2017, http://www.realclearhealth.com/articles/2017/02/09/why_is_it_so_hard_for_republicans_to_replace_obamacare_110432.html
- 5. This argument is based on Neil Barofsky, Bailout: An Inside Account of How Washington Abandoned Main Street While Rescuing Wall Street (New York: Free Press, 2012).; Brad Jacobson, “Obama received $20 million from healthcare industry in 2008 campaign,” Raw Story, January 12, 2010, http://www.rawstory.com/rs/2010/01/12/obama-received-20-million-healthcare-industry-money-2008/; Gaius Publius [pseud.], “Obama Got $20 Million from Healthcare Industry in 2008. Was Killing Single-Payer Part of the Deal?” Naked Capitalism, February 5, 2014, http://www.nakedcapitalism.com/2014/02/gaius-publius-obama-got-20-million-healthcare-industry-2008-killing-single-payer-part-deal.html