Reform Versus Resistance In GOP Health Care Politics
I wasn’t terribly surprised by the Supreme Court ruling in the Obamacare case – though I got the margin wrong (I thought Roberts and Kennedy would both be in the majority), I expected a decision to uphold the heart of the law, and I thought the argument that the mandate was really a tax to be compelling from the very beginning. I personally wasn’t worried about finding a limitation to the Commerce Clause, but it was obvious that Roberts and Kennedy were both interested in finding one. And so the majority decision did what I expected: uphold the heart of the law while making clear that it didn’t buy the argument that the Commerce Clause granted Congress plenary power to do order individuals to enter into whatever economic arrangements it sees fit.
In the wake of the decision, Ross Douthat has been gamely making the case that the GOP’s united opposition to President Obama’s health care initiative was justified from the perspective of someone who wanted to see a more right-wing version of health care reform – “universal but non-comprehensive” – triumph in the end. In his latest installment, he says:
Now it’s true that most of these Republican reforms, real and hypothetical, would not have insured [as] many people (at least initially) as Obamacare. It’s also true that in the last few years, the G.O.P. has been moving away from even a rhetorical commitment to the goal of perfectly universal coverage. But on both counts I think that the conservative approach is defensible. Given the unsustainability of our existing commitments, the central role that spiraling costs play in making insurance inaccessible, and the difficulties inherent in trying to make Washington responsible for insuring every inhabitant of what will be a nation of 400 million people by century’s end, a reform that expanded insurance substantially but not completely in the short term while putting the health care system as a whole on a sounder footing in the long run (as Bush’s 2007 proposal might have done) could be preferable, on moral as well as practical grounds, to a reform that achieves universality in the near term but ultimately brings everybody on board a sinking ship.
I think I understand the argument he’s making: we need to reform entitlements to make them more affordable before we can make them universal. I disagree with that view – I think it’s absolutely vital to get everybody into the pool together, that this is, in fact, a prerequisite to effective entitlement reform, and I think the history of the Bush Administration, which passed a huge new entitlement for existing beneficiaries while failing to expand coverage to the uninsured, bears out my view. But I understand Douthat’s argument.
What I don’t see how is how it’s a case for GOP obstructionism on the grounds that were claimed during the debate – namely, that the individual insurance mandate was a massive infringement on freedom and a government takeover of a huge portion of the economy. That argument – and a political movement powered by that argument – would seem to be exceptionally poorly positioned to make a public case for reform, because it’s not making a case for reform, but for resistance.
But perhaps there’s a second-order political logic to the stratey of resistance? Douthat himself goes on to say:
Any substantial health care reform, market-oriented as well as dirigiste, is inevitably disruptive, and (as Reihan Salam points out) the Republican coalition includes more voters who are satisfied with existing arrangements than does the Democratic coalition. As we saw in 2009-2010, to pass a comprehensive health care bill you need not only policy commitments from elected officials but immense internal pressure from the party’s activist groups and rank-and-file. The Republican coalition just isn’t as likely to generate that kind of pressure on its elected officials, and indeed certain segments of that coalition are likely to find reason to resist even the most impeccably free-market reform. Straightforward risk aversion, not ideology, is the crucial factor discouraging Republican politicians from taking the lead on the issue.
But this is precisely why the current political moment presents a unique opportunity to conservatives. The fact that the Democrats did pull out all the stops in 2009-2010, courting a giant backlash in the process, means there’s a unusually large amount of political cover for a right-of-center alternative.
If you think about what he’s arguing, Douthat is implying that, politically, the kind of health-care reform that he favors could not be achieved without the Democrats first pulling out all the stops to achieve universality. If the goal is “universal but non-comprehensive” coverage, the Democrats will have to deliver universality while the GOP reforms what the Democrats pass to make it sustainable by trimming it’s comprehensiveness. The goal of a strategy of resistance, in this reading, isn’t actually to prevent the Democrats from passing Obamacare, but to wring the largest possible political gains from the risks the Democrats take – so that these gains can provide political cover for a round of GOP-led reforms of the bill they opposed.
Now, I argued back before the ACA was passed that it was the first stage of a reform that needed to be followed by voucherizing Medicare, the goal being, ultimately, a system something like Germany’s, where universal coverage is provided individually from a variety of competing not-for-profit insurers. I’ve argued that Wyden-Ryan is plausible starting point for thinking about that next step, and that Ryan’s ideas about reforming Medicare can only work within the context of regulated exchanges such as those set up within the ACA.
But all of this was by way of arguing that wall-to-wall Republican opposition to the ACA was misguided. I don’t see how, politically, you reap the benefits of arguing that the ACA is tyranny and then turn around and say that the answer to that tyranny is to make the law more flexible and less expensive. Or, rather, I see how you could do that, but it could only work if your voters are rather Orwellian in their mentality, and basically believe the law is tyranny because Democrats passed it. Which is not, I think, a mentality you want to encourage if you actually care about democracy.
The question Douthat has been asking is: what should a Republican pundit have done during the health care debate of the first years of the Obama Administration, and what should that pundit do now? I agree with Douthat that giving up on either party is foolish. If you’re a reform-minded pundit who (for whatever reason – and that’s another question to get into another time) identifies with the GOP, you should try to persuade the party to move in the reform-minded direction you favor, however likely or unlikely it seems. But you should do that when the party is benefitting from the politics of resistance as well. Pundits are not political strategists. They have no obligation to stay on-message. The politics of resistance were hugely beneficial to the GOP in 2009-2010. But if they plausibly set the stage for “not only policy malpractice, but a moral scandal as well” then that was a good time to say so.
(I don’t mean to suggest, by the way, that Douthat joined the Tea Party chorus in 2009-2010, or that he failed to argue for a reform-minded center-right at that time. But I do think he needs to grapple with the problem that a politics of resistance presents to a reform-minded Republican like himself. I also don’t mean to suggest it’s an easy problem to grapple with – it isn’t! But I want to see a smart guy like him do more of that grappling out loud, in public.)