Whenever Obamacare is back in the news, partisan incomprehension always follows, and between the commencement of this year’s open enrollment period, the new Supreme Court challenge to the Affordable Care Act, and a certain MIT professor saying impolitic things on camera, partisan incomprehension is at a historic high.
In the spirit of fostering cross-ideological understanding, conservative writer Reihan Salam has written a lengthy article explaining both the right’s substantive opposition to the law, and its related, but more mysterious blinding Obamacare rage. One of Salam’s professional callings, as a prominent conservative reformer, is to widen the Republican Party’s appeal so that it isn’t essentially coterminous with the population of ardent Obamacare foes. For that reason, I hoped his insider’s ethnography of the Obamacare repeal movement would contain insights unavailable to those of us on the outside. But it contains no persuasive justification for the right’s extraordinary campaign against the law. And by pitting unremarkable points of contention against only glancing acknowledgements of the law’s success, it exacerbates the incomprehension it seeks to diminish.
That Republicans haven't found a ton to love about the Affordable Care Act isn’t much of a mystery to the law’s supporters. Republicans hate taxing wealthy people; they hate subsidizing poor people; they hate doing the former in service of the latter; and they want to devolve existing social programs to states and the private sector, not create new ones of any provenance. Salam mostly cops to this. He doesn’t cop to the more cynical motives animating the right’s opposition in certain precincts, perhaps because he doesn’t share them. He also doesn’t let the law’s early cost-containment successes alter the right’s view, which he presumably shares, that, “Instead of tackling the health entitlement problem … Obamacare will make matters worse.”
But in any case, none of these basic differences between liberals and conservatives explain, as Salam puts it, why conservatives are “so pissed off about Obamacare.” He attributes their indignation to the belief “that Obamacare only became the law of the land because President Obama misled the public,” then goes on to explain that conservatives aren’t hypocrites for wanting to turn Medicare into an Obamacare-like program for seniors, or for having once supported the individual mandate; then acknowledges that conservatives are miles from consensus on how best to replace Obamacare; and finally concludes that the law should be repealed anyhow.
None of this makes the Obamacare opposition seem even a tiny bit reasonable, but it does present a few good opportunities to explain why liberals think most of this is all window-dressing for a simpler explanation: Conservatives don’t just oppose distributive programs that help the poor and working class—these programs drive them batty in and of themselves. That Obamacare patched up the single biggest hole in the federal safety net, and in so doing extended government-sponsored health benefits to people through every stage of life, intensifies this reaction. Obamacare effectively settled a decades-long debate over the nation’s character in the left’s favor, and did so on a partisan basis. How could conservatives not be incensed?
But “we lost and they won” is only a justification for bad sportsmanship. The trick is to make the opposition look more sporting. Salam laments that Democrats tailored their health care legislation to obscure and delay transfers so that budget analysts wouldn’t treat the law as they might a single-payer program, where instead of taxes, expenditures, premiums, and payouts, everything coming in is a tax, and everything going out is an expenditure. I explored this issue at length last week. Suffice it to say, I think the right’s memory has grown conveniently spotty. Salam is correct to note that Democrats took steps to ensure that the Congressional Budget Office didn’t return a cost-estimate that made the law politically toxic. As a result, the law’s benefits rolled out later than they ought to have, those benefits aren't as generous as many liberals would have preferred, and insurance companies get to pocket more money than they would have otherwise. There were real tradeoffs involved. In 2011, in a different context, Salam mocked the kind of scolding he’s now directing at Obama. “Ah, he made the program marginally less politically poisonous, which will make it harder for us to demonize him. Now let’s attack him for hypocrisy!” he wrote, paraphrasing critics. The policy architect in that instance was Paul Ryan, who proposed phasing out the existing Medicare program, but only after 10 years, and only for future retirees. At the time, Salam didn’t believe his opponents’ rhetorical strategy had much merit. “I mean, I get it,” he added. “But also: let’s move on."
The Ryan Medicare plan is instructive, particularly in its original, platonic form, because it’s one of the most contentious provisions of the Republican budget, and one Salam and other conservatives have been most at pains to defend. Salam is on firmer ground when he singles out Obama for insisting that “if you like your insurance plan, you’d be able to keep it.” Obama was categorical where he should have been more measured, and thus damaged his credibility. But as many times as Obama said “if you like your plan you can keep your plan,” or some iteration thereof, I’m willing to bet Ryan has promised that under his Medicare plan, benefits for everyone over 55 would “remain as they are, without change” at least twice as often.
Just about every Republican who supports these Medicare reforms has repeated this claim in one venue or another. Salam himself once allowed that “the goal of Romney-Ryan is to protect Medicare in essentially its current form.” It is the political linchpin of Ryan's plan.
It's also no more defensible than “if you like your plan you can keep your plan.” If the phaseout Ryan proposed ever begins, younger seniors will be closed out of the old system, and as elderly beneficiaries cycled through that system, it would unravel. The beneficiary pool in both traditional Medicare and Medicare Advantage would shrink and age, Medicare Advantage plans would disappear or become prohibitively expensive, the old system would lose its powers of scale, and drive millions of seniors into the new Obamacare-like private market. The disruption would begin gradually, and then accelerate, by which point most of the people who voted for the plan—not to mention the president who signed it—would be long out of office. This is one way to moot objections of the sort that the bill only became law because the president “misled the public.”
Obama faced extensive criticism for delaying the implementation of his scheme until after his re-election campaign. If President Romney had signed the Romney-Ryan Medicare plan in 2014, been re-elected, and then passed the baton to President Ryan, the reforms wouldn’t have kicked in until Ryan’s second term.
Like Obama, Ryan and his supporters are being categorical, when they should be measured. If they manage to enact this plan some day, I’m sure liberals will be furious. I’m equally sure they will spare us the insinuation that the reforms lacked the legitimacy all other laws enjoy.
To argue that Republicans are so uniquely furious about Obamacare because of the kinds of spin and evasion that define the entire legislative process is to say Republicans don’t really have an excuse. Salam then drifts away from the purpose of his article when he argues that Republicans can support Obamacare for seniors unhypocritically. This is clearly true. Three and a half years ago, when Republicans were still feeling out their new power in Washington, and fielding fresh accusations of hypocrisy, I compared the supposed contradiction to a highway with unbridled private insurance on one end, Medicare for all on the other end, and two parties driving toward each other rapidly from opposite directions, meeting awkwardly in the middle.
If your policy trajectory intersects with ideas you wouldn’t support in other contexts, it’s not hypocrisy, it’s circumstance. Or maybe irony. The actual hypocrisy can be found in conservative, '90s-era legislative proposals that closely resemble Obamacare, and in Mitt Romney’s Massachusetts health reform. Both divided Republicans, but either could have easily become a bipartisan national health reform template, if any of the conservatives who claimed to support those visions at the time were being serious. They weren’t.
That’s because most Republicans don’t actually believe the federal government should guarantee working-age people affordable health care. Salam casts that fact in contrast to Medicare. “For better or for worse, there is now a consensus that the federal government should finance a large chunk of medical expenditures for all older Americans, and that’s been true for decades. There is no such consensus for non-elderly adults.”
This is true on Capitol Hill. It is not true in the rest of the country, where guaranteed issue, community rating, and premium support for the uninsured are all broadly popular ideas, and the very things that make repealing Obamacare outright impossible. That national consensus explains why conservatives are struggling fruitlessly to reach consensus on new ways to express these guarantees—universal catastrophic care? fewer, smaller subsidies?—without accepting Obamacare as the starting point for future reforms. Inevitably, some of them are coming to accept that the coverage guarantee must stay. Salam surveys this disarray on the right without reflecting with a single sentence on the contrast to the ACA—its successful, ongoing coverage expansion; the downward pressure it’s putting on premium increases; the public’s overwhelming satisfaction with these new benefits. Instead he declares, “I’m a firm believer in scrapping Obamacare and starting over.”
This does not ameliorate partisan incomprehension. This is the reason it exists.