Everybody’s Fault

After the failure of the American Health Care Act (AHCA)—the House Republican alternative to Obamacare—there was plenty of blame to go around. President Donald Trump pointed his finger at the House Freedom Caucus (HFC), the group of 30 or so conservatives who largely opposed the bill, tweeting, “The Republican House Freedom Caucus was able to snatch defeat from the jaws of victory. After so many bad years they were ready for a win!”

It was not just Trump making such claims. The Wall Street Journal editorial board blasted the HFC, saying they “sabotaged” the “fragile legislative balance” that the House GOP leadership was looking to build. “When one of their demands was met,” the Journal wrote, “they dug in and made another until they exceeded what the rest of the GOP conference could concede. You can’t have a good-faith negotiation when one party doesn’t know how to say yes—or won’t.”

The HFC has certainly earned a reputation over the years for bucking leadership. But they were hardly alone in killing off the AHCA. Whip counts by the major news outlets showed that moderates and party regulars were also skeptical. Indeed, the death knell for the AHCA was rung by Rep. Rodney Frelinghuysen of New Jersey’s 11th District, chairman of the Appropriations Committee and hardly a conservative hardliner. When he came out against the bill, that was that.

To be certain, the Freedom Caucus definitely deserves a quotient of the blame. After all, they had years to develop a palatable alternative to Obama-care and never did so. But their responsibility pales in comparison to the culpability of President Trump, who—as detailed by Tim Alberta of Politico—botched the sales job of the AHCA at multiple points. He alienated crucial members, sent mixed signals about his opinion of the bill, and seemed unaware of the specific issues that were dividing congressional Republicans. And the balance of the failure belongs to the House GOP leadership, including Speaker Paul Ryan. The AHCA was a bad bill.

So sure, the Freedom Caucus refused to take half a loaf and ended up with nothing. But let’s take a closer look at that loaf. The AHCA was not merely setting tax or spending levels, policy domains where splitting the difference makes sense. It was also trying to reform Medicaid and the individual insurance marketplace along more conservative lines.

The individual marketplace was the main stumbling block. This market is like a Jenga puzzle. A raft of state and federal regulations interlock with public subsidies to create a structure that if tinkered with in the wrong way will come crashing down. This is where the AHCA was a failure.

While many parts of the law were popular with conservatives, in its totality the AHCA would have destabilized the individual marketplace, or at least made it a much more difficult place for many people to buy insurance. By eliminating Obamacare’s mandate to buy insurance, keeping the regulations that inflate the price of insurance, and fidgeting around with the public subsidies, the AHCA would have left certain classes of people in the lurch. Among them are Americans in their early 60s—who, incidentally, are a key Republican constituency.

From this perspective, the HFC was not being obstinate by making all sorts of demands. It was trying to fix a bad bill. It was not refusing to take half a loaf; it was refusing Solomon’s suggestion to cut the baby in half.

The House leadership’s counter to this reasoning is that the rules of the Senate forbid them to tinker with Obamacare too much. That point remains contested, but even if it is true, it does not excuse the AHCA. Republicans are still obliged to write a good bill according to the rules of Congress. They simply did not do that with the AHCA. If a full repeal and replacement of Obamacare cannot be produced because of the Senate rules, the House GOP should have admitted as much and set its sights on a target that could be acquired—like reforming Medicaid. Indeed, doing nothing would arguably be preferable to the AHCA.

It is hard to get around the idea that for all their campaign talk over the last eight years, Republicans just do not know what to do about Obamacare. It is not for nothing that around the time that passage of the AHCA was looking shaky, Republicans began openly fretting that a protracted fight over health care would prevent it from getting corporate tax reform done. This raises troubling questions about the congressional GOP’s priorities. For seven years, repealing and replacing Obamacare has been the party’s central campaign issue, yet it is governing like corporate tax reform is its number one goal. Is the congressional GOP’s heart even in the health care fight, or was this just an empty promise made to the voters who don’t feel like they have much of a stake in a border adjustment tax?

It is striking to contrast Ryan’s efforts on the AHCA with his Medicare reform plan. Whatever the merits of the GOP’s Medicare plan, at least it is based on an idea—namely, shifting Medicare from a fee-for-service entitlement to a premium-support program. The AHCA, on the other hand, was a hodgepodge of poll-tested items—Repeal Obamacare taxes! Eliminate the mandates! Block-grant Medicaid!—in search of a central, unifying theme.

Intelligibility also differentiates the AHCA from Obamacare. The latter rests on a host of faulty assumptions. It privileges technocratic tinkering over market forces. It assumes that a relatively modest penalty will induce healthy people to sign up for insurance. And so on. But once those assumptions are accepted, the scheme is somewhat coherent: Forcing insurers to cover everybody increases premiums, but forcing everybody to carry insurance will lower them, and public subsidies will make it affordable for the middle class. The AHCA had no such internal logic.

Whether the GOP will return to Obamacare this year or even before the 2018 midterm election is not clear. For that matter, it is an open question of whether they should. The AHCA was such a poorly constructed piece of legislation that it raises doubts about the party’s commitment to the project, and even its competence. It seems as though House Republicans have not put the time and effort into thinking through a sensible alternative to Obamacare. And if that is sadly the case, then perhaps they should just leave well enough alone. Passing a bad bill would be worse than doing nothing—for then the entire blame for the many problems of American health care would shift from the Democrats to the Republicans. That would embolden the progressive left, which is already revisiting the idea of single-payer health care with a gleam in its eye.

Jay Cost is a senior writer at The Weekly Standard.

This post originally appeared on Weekly Standard


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