- Conservatives have spent years hiding their real position on health care.
- There's the 'fake' but popular version, and the real position.
- The failure of the AHCA has exposed the 'dishonest' two-step
The most interesting policy argument in America right now is the debate between conservatives' real position on health care and their fake position.
The fake, but popular, position goes something like this: Conservatives think everyone deserves affordable health insurance, but they disagree with Democrats about how to get everyone covered at the best price. This was the language that surrounded Paul Ryan and Donald Trump's Obamacare alternative — an alternative that crashed and burned when it came clear that it would lead to more people with worse (or no) health insurance and higher medical bills.
Conservatives' real, but unpopular, position on health care is quite different, and it explains their behavior much better. Their real position is that universal coverage is a philosophically unsound goal, and that blocking Democrats from creating a universal health care system is of overriding importance. To many conservatives, it is not the government's role to make sure everyone who wants health insurance can get it, and it would be a massive step toward socialism if that changed.
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This view provided the actual justification for Ryan and Trump's Obamacare alternative — it's why they designed a bill that led to more people with worse (or no) health insurance and higher medical bills, but that cut taxes for the rich and shrank the government's role in providing health care.
There was, for decades, a logic to the GOP's dual positions: the fake but popular position was used to pursue the ends of the real but unpopular position. But in the post-Obamacare world, the chasm that has opened between conservatives' fake and real positions has become unmanageable, and how — or whether — conservatives resolve it has become perhaps the most interesting public policy question going today.
On the latest episode of Peter Robinson's Uncommon Knowledge, Avik Roy and John Podhoretz have perhaps the most honest and bracing discussion of this I've heard. Podhoretz, a columnist and editor with a deep pedigree in conservative politics, begins by arguing that the passage of Obamacare, and the debate over the American Health Care Act, shows a "Rubicon" has been crossed in American politics — there is now an "almost unspoken acceptance of the idea that there should be universal coverage for health care in the United States."
The problem, Podhoretz continues, is "that was never a conservative or Republican goal," and if it is accepted as a consensus position, conservatism's actual goals are imperiled. His summation of the danger is, I think, both correct and revealing:
If Republicans cannot defend the idea that what is important is the freedom of the individual to make choices about how to live his life as opposed to the notion that we are all in this together and must all participate in health care to ballast each other's health care outcomes, then we have accepted an essential social democratic principle, and that's a huge concession.
Roy, a health care expert who runs a reformist conservative think tank, begins his rebuttal thusly: "What John just articulated is the conventional conservative view — that universal coverage is a great defeat for conservatism and a victory for progressivism." He goes on to argue that this reflects a failure of the conservative imagination, and that the possibility exists to expand freedom and expand coverage while cutting costs.
It is notable, then, that the "conventional conservative view" is so utterly absent from the rhetoric of top conservative politicians. It is part of my job to be a close listener of Republican statements on health care policy, and they virtually never admit that universal coverage is not a conservative goal, nor do they defend the idea that freedom is the ability to choose to not be able to afford health insurance.
Instead, Republicans carefully use terms like "universal access to health care" as a way of sounding like they're endorsing a world where everyone has health insurance even when they're not. Top Republicans, including Mitch McConnell, spent years arguing that the Affordable Care Act wasn't covering enough people with sufficiently generous health insurance. Then the GOP elected Donald Trump, who promised "we're going to have insurance for everybody" with "much lower deductibles."
And this tension predates Obamacare. In 2004, President George W. Bush made health care a centerpiece of his State of the Union, promising to "ensure that Americans can choose and afford private health care coverage that best fits their individual needs." And long before Bush, President Richard Nixon proposed a universal health care plan more ambitious than anything we have today. Even Ronald Reagan bowed to the consensus — his famous "there you go again" dismissal of Jimmy Carter was Reagan denying his previous opposition to Medicare.
There has not, in recent political memory, been a national Republican leader who actually argued that the American health care consensus was wrong and it was simply not the government's job to ensure every American could get health insurance.
Conservatives stopped trying to win the philosophical argument a long time ago. But they didn't stop trying to win the policy fight. They might have talked like they agreed with Roy, but they governed like they agreed with Podhoretz — because they did. And so they used whatever rhetoric was effective, and whatever political and procedural tools were available, to try to stop Democrats from passing universal health insurance plans. The strategy wasn't to win the argument over whether universal coverage was the right goal but to simply keep it from happening.
In the mid-1990s, that meant Republicans came up with universal coverage plans as alternatives to Clintoncare — but those plans were diversions, and once the danger of Clintoncare had passed, they were abandoned. More recently, conservatives attacked Obamacare (which was itself based on one of those Republican alternatives from the 1990s) for cutting Medicare and being insufficiently generous — the hope was that if public loathing of the law intensified, Republicans could stop the law or, later on, repeal it.
These tactics were reasonably successful, and America has lagged far behind other industrialized nations in developing a universal health care plan. But the strategy had the byproduct of firmly establishing liberal health care goals as the political consensus. Republicans held the line on policy by allowing total defeat on philosophy.
Now that Republicans have lost on policy too, their two-step has collapsed. As the AHCA's ignominious defeat demonstrated, with the basic architecture of universal coverage in place (even if we are still a far cry from getting everyone covered), simply protecting the status quo isn't enough — the GOP needs an alternative that people prefer to the status quo. And to Americans, a bill that's better than Obamacare is a bill that covers more people with more generous insurance.
In recent weeks, there have been rumors that Republicans will revive their Obamacare alternative by making more concessions to the House Freedom Caucus. But amid all the reporting on legislative dealmaking, there's been no suggestion that they've come up with a new way to sell their plan to the public. Instead, the strategy appears to be to continue to speak like they're committed to universal coverage while passing policy that throws millions off of health insurance, and to hope that party discipline and Trumpian magic can overcome the contradictions long enough to pass the bill.
Republicans need to realize their problem isn't poor legislative leadership or dissident House conservatives. It's that they've been hiding their real health care position for decades, and so there's no public support for the bills that actually achieve their goals. Either they need to change what they believe, and move toward the kinds of policies Roy proposes, or they need to begin the hard work of actually persuading the public that not everyone who wants health insurance should be able to get it.
Commentary by Ezra Klein, editor-in-chief of Vox. Follow him on Twitter @ezraklein.
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