The Fatal Lack of Republican Messaging on Healthcare
There is something unreal about the renewed push in the Senate to repeal Obamacare through the mechanism of the so-called Graham-Cassidy bill, named for its co-sponsors. For one thing, the messaging is a mess. It is unclear why the Senate Republicans are trying to pass the plan. I don’t mean why politically they are trying to pass it, but the fact that they don’t seem able to make a coherent argument in favor of it in public. Previous efforts to argue that Obamacare was collapsing seem to have largely been dropped, but unlike in the spring, no one seems to be trying to make an argument that the bill will improve healthcare.
The closest thing to a positive case is that the bill is about federalism and experimentation. By replacing the current formula for calculating federal Medicare transfers to states on the basis of their population of recipients, with block grants, it corrects a “free-rider” problem whereby states can define who is eligible for the program and then bill Washington for it. This is not a bad idea, the media does a disservice by playing down the catastrophic impact such perverse incentives have had in states like New York, where nearly 40% of the budget goes to pay Medicare matching expenses. The problem is that the goal is not to cap future costs, but to actually massively reduce the total expenditure so as to create savings for tax cuts. That means rather than a fairer redistribution or encouraging better behavior by individual state governments, the overwhelming impact of the bill will be to massively cut spending almost everywhere.
While Republicans are right to point out that it is a myth that there is direct proportional correlation between increased spending on services and the quality of those services, the quality of government services does tend to correlate negatively with budget cuts. And these cuts are so massive that millions will see a worse outcome, even if figures like 32 million thrown around by partisan actors are wide off the mark. The bigger problem however is not that there will be losers, Obamacare produced a lot of them too, but that there don’t seem to be any winners. At most, it might be young, healthy people who gain from the liberalization of pre-existing conditions standards, but that is a group least likely to vote, and even less likely to vote Republican. And they will likely be hit with other aspects of the bill.
Furthermore, these arguments aren’t being made. The most shocking thing about this debate is the lack of claims that Graham-Cassidy will make the healthcare system better. Rather the arguments are political and internal, that Republicans have to keep their promises for electoral reasons and to pay back donors, an embarrassing callback to when Democrats in the mid-2000s publicly aired their internal strategic differences. The GOP probably will be hurt by this bill in any case, the Democrats were by Obamacare and that involved throwing money at people, but they will definitely be hurt if they aren’t even trying to defend it allowing the opposition to define it.
If one drops any sort of claims that Graham-Cassidy or any GOP healthcare plan will increase healthcare access, then the major objection left is cost. “Obamacare is simply too expensive” is the refrain, and it has been the charge Republicans have embraced against demands for single-payer, drawing strength from abortive efforts to introduce such a system at the state level in Vermont and California. The problem with this charge is not that it is untrue, it is subjectively true depending on your perspective, but that “cost” arguments are almost always political losers. Conceding that something is a good thing, that people would benefit from it, but insisting that there just isn’t enough money runs into the problem that there is always enough money for something else, witness the recent $700bn military budget just approved by the Senate. The opposing party can always insist that the money can be found, if need be by “eliminating waste and fraud”, and being out of power they have the luxury of not having to prove their claims.
The best example of how this dynamic plays out is what happened in Britain’s June 2017 General Election. Labour recovered from a 20 point polling deficit to lose by a mere 2% running on a platform of massively increasing public spending, erasing student debt, building new housing, and nationalizing the railroads. The Conservative government had based its economic record around the principle of austerity, but their claims that there was no money available depended on not demonstrating that they could afford to waste money on other things. Once the Conservative government embraced Brexit, and abandoned austerity, the principled of increased spending was established, and the election turned into a bidding war in which the Conservatives had little chance.
The politically fatal aspect of the current Healthcare debate is not Graham-Cassidy itself, but the fact that the bill has become tied both to “tax reform” and major spending increases for defense. As such, it will be hard, if not impossible for Republicans to insist that money for health care does not exist. They merely chose to spend it on other things. That the amount consumed by defense or tax reform wouldn’t be enough to come close to supporting single-payer is beside the point. Very few voters bother with complex math. The point will be that Republicans passed a bill that made healthcare worse, then spend money on tax cuts and bombing the Middle East.
The final argument is a principled one. Republicans should support small government, and if they fail to roll back Obamacare it will prove that once a government benefit is established it can never be reversed. The fear of that “ratchet” effect means the GOP is obligated to try. Remarkably similar to justifications for ending DACA it runs around on the same cold political truth. In order to prevent future Democratic congresses or President’s from assuming the GOP is bluffing by proving the GOP was not bluffing, the GOP has to actually not be bluffing. And the simple fact is that just as Republicans are not in fact willing to pay the political price to actually reverse DACA(ie. Deporting recipients), if the rollback of Obamacare is to matter it has to be seen as an actual permanent change.
By passing a bill that will create a system that is unacceptable to almost everyone, the GOP ensures that the issue will need to be revisited in the foreseeable future, and making the future of healthcare the heart of political debate. As the GOP has nothing to say on the issue, this will ironically have the effect of doing more to legitimize Single-Payer than Obamacare ever did, because it will be the only option being seriously presented to voters to solve an untenable situation which the Republican party will be invested in defending as tenable. If Republicans were to leave Obamacare in place, it would be hard for a future Democratic administration to argue that it had a mandate to tinker, and all the arguments about “losing your plan” would have resonance again. But if it is gone, then Democrats will run explicitly on passing a new healthcare plan, potentially single-payer, and passing it will become a test of party loyalty. And as the behavior of the congressional GOP demonstrated, that can cause politicians to vote for questionable policies.
The last argument that makes sense is that this is a clever usage of the opportunity the Trump-Schumer deal unintentionally opened by removing a fight over the debt limit from the table until December. But that still presumes Republicans want to pass a plan. In fairness, they clearly do. They just aren’t sure why. And if they can’t come up with a “why” they will be in even worse shape than the Democrats were in 2010.