Against the Grain

Why Republicans Are Losing the Health Care Fight

GOP leaders sound so unconvinced about the merits of their own proposed policy that they’ve stopped trying to make the case for reform entirely.

Senate Majority Leader Mitch McConnell and Majority Whip John Cornyn speak with the media after they and other Senate Republicans had a meeting with President Trump at the White House on June 27.
AP Photo/Alex Brandon
Josh Kraushaar
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Josh Kraushaar
June 30, 2017, 10:15 a.m.

Polit­ic­al sales­man­ship is something of a lost skill these days. Sen­ate Ma­jor­ity Lead­er Mitch Mc­Con­nell draf­ted his Obama­care-re­place­ment le­gis­la­tion be­hind closed doors, without much pub­lic ad­vocacy be­hind the health care re­vamp. Pres­id­ent Trump hasn’t even tried to con­vince the pub­lic on the mer­its of the GOP’s pro­pos­al—nev­er mind the fact that he hardly seems to know what’s in the bill that he’s cham­pi­on­ing. Re­pub­lic­an sen­at­ors, many of whom were ex­pec­ted to sup­port the le­gis­la­tion, don’t want to go on tele­vi­sion to de­fend it.

This is the lo­gic­al con­clu­sion of le­gis­lat­ing without work­ing to se­cure a pop­u­lar man­date be­hind your goals. Such anti-demo­crat­ic tend­en­cies in­creased dur­ing the Obama years, when the former pres­id­ent fam­ously bragged all he needed was “a pen and a phone” to get ex­ec­ut­ive or­ders done, even while un­der­stand­ing many of his pri­or­it­ies were op­posed by a ma­jor­ity of the pub­lic. But un­der Trump, the strategy of play­ing to one’s base while ig­nor­ing the broad­er pub­lic has reached new levels.

It is re­mark­able that a party with the White House and healthy ma­jor­it­ies in Con­gress is badly strug­gling to get any le­gis­la­tion passed—no less its sig­na­ture re­peal-and-re­place ef­forts. In fact, the GOP’s health care conun­drum is of­fer­ing a case study of what hap­pens when you draw the vot­ing pub­lic en­tirely out of the pic­ture, ig­nor­ing the role that per­sua­sion plays in get­ting things ac­com­plished.

Pub­lic opin­ion on the ori­gin­al Sen­ate health pro­pos­al is abysmal. The most re­cent round of polling shows any­where from 12 per­cent (Suf­folk/USA Today) to 27 per­cent sup­port (Fox News) for the re­peal-and-re­place le­gis­la­tion. This plan has been so poorly sold that even the nor­mally faith­ful Re­pub­lic­an base isn’t be­hind it. Rather, a 40 per­cent plur­al­ity of Re­pub­lic­an voters said they don’t have any idea of what’s in the le­gis­la­tion, ac­cord­ing to this week’s Quin­nipi­ac sur­vey. That’s a few points high­er than the num­ber of Re­pub­lic­ans who sup­port it.

At a time when the pub­lic is so polit­ic­ally po­lar­ized, that de­gree of in­tra­party de­fec­tion is hard to achieve.

To be sure, the sub­stance of the policy it­self is driv­ing its un­pop­ular­ity. Tak­ing away en­ti­tle­ments will al­ways be a tough sell re­gard­less of ef­fect­ive spin, and the le­git­im­ate voter anxi­ety over po­ten­tially los­ing health care be­ne­fits as a res­ult of the re­place­ment pro­pos­al is driv­ing much of the neg­at­iv­ity. But those as­sump­tions also un­der­value the un­pop­ular­ity of Obama­care.

In a va­cu­um, the GOP’s re­place­ment plan is an epic polit­ic­al dud. But when asked if the GOP Con­gress should con­tin­ue ef­forts to “re­peal and re­place” Obama’s health care law in the most re­cent NBC/Wall Street Journ­al sur­vey, 38 per­cent agreed while 39 per­cent op­posed. That sug­gests Amer­ic­ans are still deeply di­vided on Obama­care’s ef­fect­ive­ness, and are open to sup­port­ing an al­tern­at­ive that re­duces man­dates, lowers premi­ums, and rolls back taxes—even if it lim­its the scope of cov­er­age.

One ma­jor flaw with the polit­ics of Obama­care was that it cre­ated win­ners and losers, re­dis­trib­ut­ing health care be­ne­fits to those who had been un­in­sured while rais­ing rates for the middle class (on the in­di­vidu­al ex­changes) and in­ef­fect­ively man­aging in­creased de­mand for over­taxed med­ic­al pro­viders. Past en­ti­tle­ment pro­grams con­ferred an over­all be­ne­fit to every­one; Obama’s law ef­fect­ively re­dis­trib­uted be­ne­fits from one group to an­oth­er.

Giv­en that real­ity, re­vers­ing it in­ev­it­ably will cre­ate an­oth­er set of win­ners and losers. That doesn’t mean any re­place­ment pro­pos­al should be his­tor­ic­ally un­pop­u­lar. If Re­pub­lic­ans tried to make the case that gov­ern­ment spend­ing on health care was crowding out re­sources for oth­er pub­lic pri­or­it­ies, they might have a cap­tive audi­ence. If they made the case that health care out­comes for those on Medi­caid aren’t good, and it’s prefer­able to have more re­cip­i­ents on private in­sur­ance, they’d be mak­ing a cred­ible case. If they even made the simple ar­gu­ment that the taxes and man­dates on busi­nesses from Obama­care are slow­ing eco­nom­ic growth, they’d have a re­cept­ive con­stitu­ency.

They still could lose the over­all ar­gu­ment, but it’s a safe bet that simply by mak­ing a pos­it­ive case for re­forms, pub­lic sup­port would rise and it would be easi­er for Mc­Con­nell to wrangle 50 votes from his caucus. In­stead, the bill is be­ing viewed as a heart­less hit job that would ef­fect­ively kill thou­sands of sick, un­in­sured Amer­ic­ans. Even the polit­ic­ally cau­tious Hil­lary Clin­ton got in the act, say­ing Re­pub­lic­ans would be­come the “death party” if the Sen­ate le­gis­la­tion passed.

Trump de­serves most of the blame for this de­bacle, giv­en his ad­min­is­tra­tion’s pri­or­ity on simply get­ting health care le­gis­la­tion passed—no mat­ter what’s in it. This is the first time in re­cent memory when the le­gis­lat­ive branch is lead­ing the charge on con­sequen­tial le­gis­la­tion, ab­sent ex­ec­ut­ive guid­ance of what to pri­or­it­ize in a re­place­ment plan. Pres­id­ents typ­ic­ally are able to util­ize polit­ic­al clout to as­sert their prerog­at­ives and per­suade way­ward sen­at­ors to get with the pro­gram. With low ap­prov­al rat­ings and min­im­al com­mand of policy, Trump has none of that cap­ab­il­ity.

So Mc­Con­nell will keep chug­ging along, des­per­ately try­ing to craft some le­gis­lat­ive com­prom­ise that can sat­is­fy Re­pub­lic­an mod­er­ates and con­ser­vat­ives alike. Don’t bet on it suc­ceed­ing. Even the best-laid plans need some pub­lic sup­port be­hind them. And Mc­Con­nell isn’t get­ting any help from any­one—wheth­er it’s the pres­id­ent, his own Sen­ate, or even his party’s top com­mu­nic­at­ors—in selling such wide-ran­ging re­forms to an un­aware elect­or­ate.

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