Why Wasn't Trumpcare More Popular?

Conservative health-care analysts on why the GOP couldn’t come up with a stronger replacement for Obamacare

Yuri Gripas / Reuters

Spring is a time for rebirth, and at least for some Republican leaders, that goes for health-care legislation, too. Talks have reportedly resumed on reviving a version of the Republicans’ Obamacare alternative, the American Health Care Act, as my colleague Russell Berman reports, even as House Speaker Paul Ryan called Obamacare the “law of the land” just a few weeks ago.

The bare bones of the AHCA will likely form the basis of whatever the party does next on health care, according to two Republican Capitol Hill aides. That might be concerning to the various physician, hospital, and insurance groups who opposed the bill, not to mention the many conservative, centrist, and liberal health-policy wonks who reviled it. (One of the staffers said outside groups simply misunderstood “what our bill did and did not do.”)

The AHCA’s epic failure, and potential resurrection, makes it worth asking—why has it been so difficult for Republicans to come up with something that’s at least more popular than the IRS? (To name just one example, Politico magazine, a publication not exactly known for partisan snark, called the bill “a Dumpster fire.”) And will anything be different if Republicans try their hand at health-care reform again?

I spoke with half a dozen conservative-leaning health-policy experts for their take on why Republicans didn’t have something better than the AHCA ready. Four broad theories emerged:

Republicans just didn’t give themselves enough time

A decade ago, the Democrats also had conflicting health-care ideas, squabbling over single-payer and a public option, but they worked it out in legislation, says Dan Holler, the vice president of communications for Heritage Action for America. “That’s not something that was capable of happening in 17 days” for Republicans, he said. The rush to pass the AHCA “was a misread of where the [Republican] conference was.”

James Capretta, with the American Enterprise Institute, said outside groups—he implicated Heritage Action and Club for Growth—were urging Republicans to repeal Obamacare as quickly as possible. Because of that, House Republicans “didn’t give themselves enough time to ... develop [Paul Ryan’s plan] ‘Better Way’ into a more politically viable replacement plan.”

Perhaps it would have become more palatable if they had spent nine months on it, as the Democrats did on Obamacare.

It wasn’t clear what the goal was

“Repeal and replace” seemingly meant different things to different Republicans. Moderates wanted to protect the law’s more popular provisions while tweaking its subsidy structure. The House Freedom Caucus thought Obamacare should be uprooted entirely. It’s hard to write a bill that simultaneously bolsters and destroys a federal program.

John Goodman, with the Independent Institute, believes the AHCA was authored in a way such that it would cut federal spending—the goal of conservative Republicans—not necessarily boost health-care coverage. The comparatively lower health-insurance enrollment levels under the AHCA were a feature, not a flaw, in other words. “If 24 million people don’t get health insurance, 24 million people won’t be getting subsidies through Medicaid or through the tax credits,” Goodman wrote in Forbes recently. “That means less spending.”

There are only so many ways to do health-care reform

Some nicknamed the AHCA “Obamacare lite,” and it does, indeed, have lots in common with the Democrats’ law. But it was also similar to past GOP proposals, like Health and Human Services Secretary Tom Price’s “Empowering Patients First” plan, as well as the plan offered up by Jeb Bush on the campaign trail. In fact, a 1989 plan from the Heritage Foundation—the one that started it all—also included tax credits and an individual mandate.

“Every time I put Obamacare in my search engine, someone has a snarky headline: ‘Republicans are starting to like Obamacare,’” said Bob Laszewski, an insurance-industry analyst. “The original outline was their idea!”

That’s because there are two basic models for health systems, Laszewski says: single-payer or Obama/Ryan/Trump/Heritage/PriceCare. One is a government-run system offers a rudimentary plan to everyone. The other one is a delicate Jenga tower of mandates, credits, and incentives, all balanced on the rickety table of the private-insurance industry.

Republicans had to go with the AHCA, that is, because there just aren’t that many other, non-socialist ways to do health insurance coverage.

And why did it take them so long—seven long years of the Obama administration—to come up with this particular formulation? Laszewski reminded me that the Democrats also hemmed and hawed for years over health care—decades, if you include the Hillarycare debacle of the early ’90s. Ultimately they settled on Obamacare, helping the poor at the expense of the better-off, while the AHCA would have done the opposite.

In other words, “when the Democrats had their shot, they took care of their base,” Laszewski said. And the Republicans took care of theirs.

Republicans just aren’t into health-care policy

Most politicians’ knowledge of the issues is “miles wide but less than an inch deep,” says Michael Cannon, the director of health policy studies at the Cato Institute. When it comes to many Republican policymakers and health care, though, that depth might be closer to a centimeter.

The reason? Republicans tend to like limited government, and health-care legislation is, well, governmenty. Sure, you could de-regulate health care to reform it, but usually new health laws result in the federal government telling doctors, insurers, or states to do something. That just isn’t the GOP’s thing!

“When Republicans have tried to apply their limited-government philosophy to health care, they’ve been beaten over the head by Democrats who say you’re trying to take away access to care,” Cannon said. “They’ve decided, ‘I don’t want to get hit on the nose with a crowbar anymore. I’m going to focus on other issues.’”

But their disinterest hurts them even more, Cannon says. Moderates in the House fear being pilloried at town halls and in ads for voting for a law that might make medical care more expensive. But Cannon feels they haven’t put much effort into explaining what they think is wrong with Obamacare’s more popular provisions, like the ban on excluding people with pre-existing conditions. “They just haven’t done their homework,” Cannon said.

“We used to say Republicans didn’t have the health-care gene,” added Merrill Matthews, a resident scholar with the Institute for Policy Innovation. “It just was not their issue.”

Now that health care is the Republicans’ problem, though, maybe it will become their issue, as well.