The health-care plans people like are ones such as Medicare, or employer-sponsored insurance — plans in which all customers pay the same rates regardless of age or preexisting conditions, and which don’t put them at risk of paying out huge costs if they get sick. #Obamacare is less popular than those kinds of insurance because it has more market features. There’s more age discrimination, and higher deductibles designed to force consumers to be price-conscious. Republican health-care plans go much, much farther in this direction. They offer threadbare, catastrophic coverage with enormous deductibles. The English, vernacular term for the kind of insurance Republican health-care plans would offer is “crappy.” There is no world in which Republicans are going to give people “something terrific” or even close to it.
Covering people who can’t afford to pay for their own medical care means making other people pay for it. You can do that through direct tax-and-spend transfers, or through indirect regulatory methods (like making insurance companies overcharge healthy people and undercharge sick ones). Republicans oppose these methods because they oppose redistribution in general. And yet politics requires them to promise a plan that does not deprive Americans of access to treatment. This is the reason none of their plans has advanced beyond the white-paper concept phase —either they contain too much redistribution to be acceptable to the GOP, or too little coverage to be acceptable to the public, or both.
But any plan to replace Obamacare with something “terrific,” or even something almost as good as Obamacare, will violate conservative dogma. There’s no way around this. Despite the apparent complexity of the issue, it’s a very simple problem of resource allocation. In a free-market system, tens of millions of Americans will not be able to afford medical care because the cost of their treatment exceeds their income, either because they’re too poor, or because they’re too sick. A Kaiser Family Foundation analysis finds that 52 million Americans under the age of 65 have preexisting conditions that would make it impossible for them to purchase health insurance in the individual market that existed before Obamacare. An insurance-industry study from 2008 found that 13 percent of people who applied for coverage in the individual market were rejected — a figure that doesn’t even count the 34 percent of people who had to buy policies that excluded coverage of treatments for their preexisting conditions, let alone those who didn’t even bother applying because they knew they couldn’t afford it.
From the standpoint of the most ideologically committed elements of the conservative base, destroying Obamacare was always the most salient pledge. Republican rhetoric treated the law as an existential threat to American freedom — the worst thing since slavery, as incoming Trump cabinet member Ben Carson put it. But from the standpoint of the electorate as a whole, the pledge to replace it with “something terrific,” as Trump put it, mattered just as much. A large number of Trump voters who get coverage through Obamacare “simply felt Trump couldn’t repeal a law that had done so much good for them,” reports Sarah Kliff, who spoke with many of them.
The Republican Party has used health care to its advantage for the last seven years by following the same strategy: advocating an alternative plan that does not and cannot exist. During this entire time, President Obama has held power. This has afforded them the luxury of posturing against the status quo — and, indeed, doing everything in their power, at both the federal and the state level, to make it worse. Republicans could denounce the messy negotiations in Congress, and then the messy reality of American health care, while promising that giving them power would let them start over and design a new reform that would protect everybody without having any objectionable features. After the election unexpectedly put them in full control of government, I predicted they would follow a “#repeal and delay” plan, because it is the only way to keep the lie going. The closer they get to taking action, the more clear it becomes to Republicans that their own propaganda has trapped them and given them no escape. Railing against Obamacare was easy, but the responsibilities of power have taken all the fun out of denying medical care to the poor and sick.