The Republican effort to repeal the Affordable Care Act is not going well, in large part because it turns out that making sweeping changes to a system that encompasses one-sixth of the American economy turns out to be rather more complicated than they imagined. Their backtracking has an interesting character to it, in particular how they've been gobsmacked by the transition from shaking their fists at the system to being responsible for it.
Up until November, they had been pursuing a strategy they got straight from Marx and Lenin, but now that they're in power, it suddenly looks like a terrible idea. Here's the latest fascinating pirouette they're undertaking, as explained in an article in U.S. News & World Report:
"House Republicans and the Trump administration on Tuesday filed a joint motion seeking to delay lawsuit proceedings that threaten to undo President Barack Obama's health care law, the Affordable Care Act.
"The House v. Price suit — formerly known as House v. Burwell, as it was filed when Sylvia Mathews Burwell was health and human services secretary — has presented Republicans with one of their most straightforward routes toward fulfilling their stated desire to do away with or dismantle Obamacare.
"Yet in the absence of an Obamacare replacement plan, the outcome the GOP initially sought threatens to upend the insurance marketplace and jeopardize coverage for millions of people."
Just to be clear, Republicans are asking the court to delay their own lawsuit pretty much indefinitely, because they've become terrified of what would happen if they succeed. In this case, it concerns government subsidies to pay out-of-pocket costs for people with low incomes. The fact that this case is now called House v. Price (as in Tom Price, President Donald Trump's secretary of health and human services) shows the contradiction. Now neither the GOP House nor the Trump administration wants the lawsuit to succeed, though they won't say this aloud — because that would mean billions of dollars in payments to insurers would cease, and as a consequence the insurers would either hike premiums or pull out of the individual market.
The ensuing catastrophe — exactly what Republicans were hoping for when they filed the lawsuit and Obama was president — would now be their responsibility alone, so they're scrambling to stop if from happening.
Republicans used to say (and sometimes still do) that the ACA would "collapse under its own weight," but they weren't satisfied to simply wait for that to happen; if it didn't, they would urge judges in friendly courts to help it along. So they filed one lawsuit after another to undermine various features of the ACA. The suits shared a simple principle: If they were successful, they would increase the amount of pain and suffering Americans endured, in the hopes that the public would then turn against the law and the Obama administration.
It's a classic Marxist strategy known as "heightening the contradictions," in which you intentionally exacerbate the problems you're criticizing the ruling powers for creating, in the hopes of bringing your revolution all the closer.
The problem Republicans face now is that their essential values on health care are in contradiction with what the public actually wants. Let me refer you to a tweet House Speaker Paul Ryan sent out Feb. 21, apparently after he stayed up late rereading his dog-eared copy of "Atlas Shrugged": -This is what Ryan and his Republican colleagues actually believe. Put aside that it misunderstands the very idea of "insurance," or that it's plainly ridiculous, particularly if you apply it to other areas of government regulation ("Freedom is being able to buy meat that might poison you; food safety regulations are Washington telling you what to buy regardless of your needs"). It accurately represents conservative thinking on health care, which is that the government should just butt out and let the market work its magic. We'll all have the "freedom" to get insurance or not, and if you can't afford it, too bad.
But Republicans know that putting those values too directly into action would be a political disaster, particularly now that the ACA is in force and millions of people are benefiting from it, not just the 20 million or so who are newly insured but also everyone else who has health security for the first time, knowing that they can get insurance no matter their income or their pre-existing conditions. So Republicans are madly trying to come up with some way to reconcile their values and political reality, something they have yet to figure out how to do.
They say they want to give Medicaid "flexibility" when, let's be honest, they'd really prefer that Medicaid cease to exist (it's a big-government program that helps poor people, which in their book is two strikes against it). They say they want everyone to have "access" to insurance, in the hopes people will mistakenly believe they want everyone to have insurance, when in truth under their plans we'd have "access" to insurance the same way we all have "access" to BMWs. They decry increasing out-of-pocket costs, while all their plans would massively increase out-of-pocket costs, which of course some people are better able to pay than others. They want to privatize and then slash Medicare, but they say their only interest is in "strengthening" it.
You may say, don't Democrats do the same thing? Don't they hide their socialist goals behind intricate policy structures that merely claim to maintain the private nature of the American insurance market? Not really, no. I don't recall any Democrats pretending that the ACA's maintenance of the privatized nature of the American health insurance market was anything but a compromise, something they had to accept because of political reality and the policy complexity of transforming the health-care system to single payer in one fell swoop. Even Obama acknowledged that, after supporting single payer for much of his early career. "If I were starting a system from scratch, then I think that the idea of moving towards a single-payer system could very well make sense," he said in 2009. "That's the kind of system that you have in most industrialized countries around the world. The only problem is that we're not starting from scratch."
Yes, most liberals consider their preferred system — perhaps single payer, or a hybrid system with guaranteed coverage, akin to what Medicare recipients currently enjoy — to be an eventual goal. But they don't see it as one worth investing too much energy into advocating right at the moment. Or at the very least they see it as something we could reach only through an incremental process involving multiple stages of reform spread out over decades. But they don't hide this fact, whereas Republicans are constantly dissembling about what their actual goals on health care really are.
And now that they actually have the chance to change the health-care system, heightening the contradictions not only doesn't work but will also hurt them. So they don't know what to do.
Paul Waldman is a contributor to The Plum Line blog, and a senior writer at The American Prospect.
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