“Obviously, it is the case that there were not enough conversations about ‘replace,’” Brian Blase, a conservative health-policy expert who was a top domestic-policy adviser in the Trump White House, told me. Dean Rosen, a GOP leadership aide from the early 2000s who went on to become one of Washington’s most influential health-care strategists, said, “There was an intellectual simplicity or an intellectual laziness that, for Republicans in health care, passed for policy development. That bit us in the ass when it came to repeal and replace.”
One reason for this laziness was a simple lack of interest. For decades, Republicans had seemed interested in health-care policy only when responding to Democratic policies required it. “Republicans do taxes and national security,” Brendan Buck, a former GOP leadership aide, quipped in an interview. “They don’t do health care.”
That ambivalence extended to the GOP’s networks of advisers and advocates. The cadre of Republican intellectuals who worked on health policy would frequently observe that they had very little company, talking about a “wonk gap” with their more liberal counterparts. “There are about 30 times more people on the left that do health policy than on the right,” Blase said.
Another problem was a recognition that forging a GOP consensus on replacement would have been difficult because of internal divisions. Some Republicans wanted mainly to downsize the Affordable Care Act, others to undertake a radical transformation in ways they said would create more of an open, competitive market. Still others just wanted to get rid of Obama’s law and didn’t especially care what, if anything, took its place.
“The homework that hadn’t been successful was the work to coalesce around a single plan, a single set of specific legislative items that could be supported by most Republicans,” Price told me. “Clearly, looking at the history of this issue, this has always been difficult for us because there are so many different perspectives on what should be done and what ought to be the role of the federal government in health care.”
The incentive structure in conservative politics didn’t help, because it rewarded the ability to generate outrage rather than the ability to deliver changes in policy. Power had been shifting more and more to the party’s most extreme and incendiary voices, whose great skill was in landing appearances on Hannity, not providing for their constituents. Never was that more apparent than in 2013, when DeMint, Senator Ted Cruz of Texas, and some House conservatives pushed Republicans into shutting down the government in an attempt to “defund” the Affordable Care Act that even many conservative Republicans understood had no chance of succeeding.
The failure to grapple with the complexities of American health care and the difficult politics of enacting any kind of change didn’t really hurt Republicans until they finally got power in 2017 and, for the first time, had to back up their promises of a superior Obamacare alternative with actual policy. Their solution was to minimize public scrutiny, bypassing normal committee hearings so they could hastily write bills in the leadership offices of House Speaker Paul Ryan and, after that, Senate Majority Leader Mitch McConnell.