The collapse of the Senate Republican health care bill isn’t all that complicated and shouldn’t come as much of a surprise. Like some bad marriages, you can chalk it up to “irreconcilable differences.” The Senate Republican Conference includes very conservative members who to their marrow believe in minimalist government, especially when it involves health care. But it also includes senators who believe that government should provide a social safety net for the less fortunate, particularly when it comes to health care. Those are close to being diametrically opposite points of view.
That very wide gulf makes it hard to believe that the two factions are in the same party. The ideological separation is wider than the one that divides House Republicans or, for that matter, Senate and House Democrats.
Congressional Democrats believe that there should be a relatively active role for government in regulating the economy, maintaining a social safety net, and providing health care. The only disagreements are over degree—how much government should intervene in economic and business matters and how broad the safety net should be. Not long ago Democrats had the kind of ideological differences that Republicans have today. A substantial number of them, particularly from the South and small-town and rural America, were fundamentally pretty conservative, even more so than some Republicans, particularly those from New England and the Northeast. There was genuine ideological diversity in the Democratic caucus that is largely muted today.
In the fight over the Affordable Care Act in 2009 and 2010, Democrats had a hard time getting behind a single piece of legislation, and that was at a time when they had huge legislative majorities, much larger than the ones the GOP has today. Republicans now have less margin for error, and in hindsight it seems that their effort to “repeal and replace” was doomed from the beginning. Even though virtually all congressional Republicans believe that Obamacare is badly flawed, settling on an alternative is a far more difficult matter.
It also makes a difference that many Republican senators have constituencies that are more ideologically and demographically diverse than those of their House counterparts, who represent districts that for the most part are clearly red or blue. So even Republicans who are not particularly moderate, but who have a lot of constituents who might be adversely affected by jettisoning Obamacare or trimming Medicaid, experienced political heartburn over the issue.
While Maine’s Susan Collins and Alaska’s Lisa Murkowski are in fact pretty moderate, Jerry Moran of Kansas, Rob Portman of Ohio, and Cory Gardner of Colorado are old-fashioned conservative Republicans. None are known to make trouble for the Republican leadership, but all had misgivings about the party’s health care legislation and its impact on their states. At the other end of the spectrum, Mike Lee of Utah is extremely conservative and Rand Paul of Kentucky is more libertarian than conservative. The GOP bill would have given government a much bigger role in health care than either could stomach.
The real question is not why the Senate Republican health bill failed but why anyone thought it had a chance in the first place. It’s my view that the only way that the deeply troubled Affordable Care Act can be fixed is if pragmatic members from both sides of the aisle go into a back room, hash out what the government’s role should be, and address the ACA’s defects accordingly. The solution must be a compromise that doesn’t favor the single-payer crowd on the left or the free-market crowd on the right. Neither party has 60 votes in the Senate, but there are certainly 60 votes between the two extremes, assuming reasonable lawmakers try hard enough to find them.
The Republican and conservative base despise Obamacare so much that any effort to reform or repair the ACA was seen as legitimizing what they see as an evil piece of legislation. Maybe after this mess is over, Republican members who are inclined to fix a troubled system will be allowed by their constituents to come to the table, work quietly with Democrats, and come up with a plan that can stabilize insurance markets and address the shortcomings of the ACA.
For their part, Democrats have to get over the idea that the ACA was an immaculate conception and should not be tampered with in any way. All huge and complex pieces of legislation have aspects that don’t work as well as hoped and constantly need fine-tuning. This law is no exception. Maybe over the next year or two, in a very different political context, something constructive can be done about health care. But it isn’t happening right now.
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