Understanding the GOP's health care failure — and the deeper existential crisis of conservative politics

Political scientist David Hopkins on how the GOP's health care debacle reflects the party's unsolved problems

By Paul Rosenberg

Contributing Writer

Published April 23, 2017 4:00PM (EDT)

 (Getty Images/Justin Sullivan)
(Getty Images/Justin Sullivan)

The Republican effort to repeal (and replace — they promise!) Obamacare died so quickly it made folk’s heads spin. But with persistent rumbling that the GOP will try again, it’s worth taking a closer look at why conservatives failed so spectacularly the first time around — and why things are so unlikely to change.

While press attention tended to focus on a few key actors — President Donald Trump, House Speaker Paul Ryan, the House Freedom Caucus — political scientist David Hopkins had a different view, expressed in two posts (here and here) on his blog, Honest Graft. He saw what happened as reflecting the basic nature of the GOP as an ideological party quite different from the Democrats, a view he explored in depth, along with co-author Matt Grossman, in the 2016 book "Asymmetric Politics: Ideological Republicans and Group Interest Democrats," which I reviewed here last August.

At the time, one could argue that Trump was just as unexpected and inexplicable from the Republican perspective as he was from anyone else’s. After all, we heard endlessly about how Trump was anathema to true conservatives. Which is why Trump’s first brush with big-ticket legislation proved to be so revealing. What was novel about Trump may have dominated attention during the campaign, but what confounded him in governing was a long-standing conundrum conservatives have wrestled with for generations. In order to better understand and appreciate the argument, Salon spoke with Hopkins about the repeal efforts, the light they shed on his theory of asymmetric politics, and what we should look forward to in the months ahead.

Could you first describe the thesis of "Asymmetric Politics" and then say a few words about how the health care fight illustrates that?

The thesis of the book is that the two major parties in American politics are fundamentally different kinds of parties. The Democrats are best understood as a coalition of social groups, and the Republicans are best understood as the agent of the conservative ideological movement. We argue that this asymmetry is apparent in virtually every aspect of party politics, from elections to Congress to interest groups to the news media, and that it explains a lot of what's going on in the American political environment today.

Health care is a particularly good example, and has to do with the fact that the American public collectively leans to the right in terms of its abstract ideological predispositions, but it also leans to the left with respect to specific policy views. So, when conservatives talk about shrinking government, or making sure that individual liberty is protected, they are speaking for a majority of Americans. But when liberals and Democrats are in favor of expanding health care access, and using the government to help regulate insurance companies, and provide insurance to people don't have it, they're also speaking for a majority of Americans.

So health care debates often take the form of Democrats arguing in favor of specific policies and Republicans respond by saying, "That's big government, that that's infringing on individual liberty, that's violating free market principles," and so on. The entire time we’ve been debating health care in this country as a federal issue, going all the way back to the 1930s and '40s, the debate has taken that form.

With that background in mind, how did this play out, first with the passage of Obamacare, and then with the GOP’s efforts to repeal it?

One of the lessons the Democrats have learned over the years has been that rather than trying to blow up the current system and start over, the most politically viable option was to work around the status quo. So the Affordable Care Act was a complicated and inelegant attempt to address those who are uninsured, while protecting to the extent possible the system enjoyed by people who are already insured. That was a fundamental philosophy of policymaking that underscored that particular legislation.

Most of the provisions of the Affordable Care Act are popular with the public. Expanding the Medicaid program was popular, requiring insurance companies to offer insurance regardless of pre-existing conditions was popular, providing subsidies from the government to allow people who couldn't previously afford insurance to purchase it was popular,. So at the specific policy level, the Democratic health care plan offered the majority of the public what it wanted.

However, it also represented in a larger sense an expansion of government power. So the Republican leadership very successfully attacked the plan as a whole for being a government takeover, and that obviously contributed to the Republican gains in the 2010 midterm elections, and prevented the Obamacare bill as a whole from being seen as a popular success in. Even though people liked much of what was in it, they didn't like the plan as it stood.

Now fast-forward to this year. Republicans have been promising to repeal Obamacare, so running on repealing it and replacing it with some unspecified superior alternative was smart politics for the party. As we all know, the party in Congress voted dozens of times in solid symbolic votes during Obama's presidency to repeal the Affordable Care Act.

Once Trump became president, and repeal became an actually viable possibility with a Republican president, all of a sudden Republicans had to confront the fact that repeal would actually involve undoing a lot of specific policies that were popular, and would result in a significant increase in the number of uninsured. At that point the political risk that the party was taking on by considering repeal increased considerably, and even Obamacare itself became popular as the debate shifted from an abstract debate over the responsibilities of government to a specific debate about revoking popular policy.

So the Republicans, to this point, have failed to even marshal support within their own party for repealing the bill, and have not been able to come up with an actual replacement that would satisfy the demands of the public while also remaining true to conservative principles.

In one blog post you pointed to the GOP's lack of interest in the Congressional Budget Office score — how many people would lose health care coverage — as a point supporting your argument. What was going on there?

One aspect of party asymmetry is that Democratic policymakers tend to be mostly outcome-oriented. The structure of Obamacare is not something that comes out of liberal ideology. It’s something that comes out of the pragmatic attempt to achieve a goal of reducing the uninsured, by the most politically viable way possible. This is because Democratic constituencies care a lot more about outcomes than they do processes. For Democrats to have the Congressional Budget Office study their health care plans and certify that the outcome will be a reduction in the ranks of the uninsured was key to the whole process. There would have been no point to having a health care plan that didn't pass CBO muster, and didn't, by expert opinion, result in the specific policy outcomes that Democrats were seeking.

Whereas for Republicans, as a party that's more interested in staying true to a set of principles than to achieving a specific set of outcomes, government expansion of health care is problematic by definition. So the actual outcome is not necessarily what's most important to them, it's the fact that you're using government in this particular fashion. So, the CBO score was politically damaging, but the fact that they were willing to write the bill and start the legislative process before they even had the score in hand showed that they had a certain level of indifference towards what the actual impact of the bill would be on the availability of health insurance for the public.

You pointed to the role of conservative activists in defeating the Ryan bill, for not going far enough. Why is that significant, and what questions does it raise about Ryan as a political leader?

The Republican Party has splintered into two different sets of conservatives. Conservative purists, like the House Freedom Caucus, and people in the Senate like Ted Cruz and Mike Lee. And then somewhat more pragmatic conservatives, that the Republican congressional leadership is aligned with. One of the stories on health care is that the purist conservatives have been willing to oppose legislation that is been developed by the party leadership and supported by the rest of the party, on the grounds that it doesn't go far enough in achieving conservative aims. This is ultimately counterproductive to the achievement of conservative aims, because when the Democrats oppose as well, all of a sudden leadership lacks the votes to move legislation through the House.

We saw this particularly on health care, when even Paul Ryan's reputation as a conservative in good standing was not able to convince these purists to sign on to his health care bill because it did not represent a clean repeal of Obamacare. Anything he tried to do to address the demands of the Freedom Caucus would have cost him votes among the members of the party that represent competitive districts. This dynamic makes it difficult for Republicans to achieve actual policy gains, because it's easy for them to wind up in a very damaging debate over ideological purity, which in practice means that the status quo prevails, at least for now.

After the bill died, you wrote in your second post “Replace Trump and Ryan with Marco Rubio and John Boehner, or Jeb Bush and Kevin McCarthy, and the results would almost certainly be more or less the same.” Why is that?

It's common for the news media to focus on individual personalities when looking at politics, and Trump himself is such a unique personality that it’s very natural to talk about the failure of Republican health care reform as being a product of Trump's individual mistakes, or Paul Ryan's individual mistakes, as if there was something about them personally that made the repeal effort fail. But our view, from the asymmetric-politics perspective, is that this is much larger than individual politicians, this is a larger pattern in the parties themselves.

We could swap out one set of leaders for another set of leaders and the Republican Party would still behave more or less the same. The dynamics on this issue — between the purist conservative yearning for clean repeal or rollback of domestic social policy and the reality that achieving that would be politically risky, and probably invite serious electoral backlash — is a dilemma that has faced conservatives for decades.

It's one of the reasons why even though the Republican Party has become much more conservative over time, and even though it's also become much more electorally successful over time, particularly in Congress, those two trends have not yet added up to a sustained rightward shift in the direction of federal policy. That has been a source of great frustration for many conservative activists, and leads to further recrimination and accusations within the party that Republican politicians are not really standing up for conservatism.

That's a dynamic that has become very damaging. Within the Republican Party this has led to primary challenges, the rebellion against John Boehner as speaker, and other observable phenomena over the past few years of. As we like to point out, there's really no corresponding trend on the Democratic side. Nancy Pelosi lost the majority, and yet she’s still party leader. So we think it's much bigger than Trump or Ryan. You could have a different Republican president, and you could have a different Republican speaker, as we did not long ago and have exactly the same dynamic.

Now that Republicans are making noises about trying to pass health care legislation again, what are the prospects? Is there any reason anything will be any different this time?

There's no reason to believe anything's really changed, so there's no reason to believe that a different bill could be written that could simultaneously gain more support among the Freedom Caucus and escape the larger political problems associated with trying to roll back health care access. My sense is that a lot of the discussion of about repeal in the House is motivated more by the desire to pass something through the House and dump it in the Senate than to actually achieve something that would be enacted and go to the president to be signed.

It seems to me that there are various House Republicans who don't want to give up. They don't want to acknowledge their failure, and they're still hoping to try to escape blame in conservative ranks for failing to repeal the ACA. The Trump administration, as well, would prefer not to have to admit defeat so quickly and so dramatically on the issue. But it doesn't seem to me, in the month or so since the first bill failed, that they’ve come any closer to resolving any of the problems that sunk that bill, or healing any of the divisions in the Republican Party that that bill exposed. 

Pulling back from health care, you point out that Trump’s ascension to power is widely seen as “a more-or-less random event — the hostile takeover of an otherwise sound party apparatus,” but you argue that the GOP’s dysfunction left it wide open to Trump, so his emergence reflects a bigger problem.

One of the lessons that Trump teaches us is that there is something of a crisis in the Republican Party. A fully healthy party is not really open to a Donald Trump coming along and walking away with this presidential nomination. I think we see a set of weaknesses in the party that he was able to exploit. One of them is a prevalent feeling among a lot of conservatives that the existing leadership of the Republican Party had failed to be an effective opponent of Barack Obama, and had failed to achieve conservative victories while governing, going back to the Bush years. Therefore there was an openness to an outsider figure who could come along and claim that he had no responsibility for any of the party's previous failures, and also that he had spent the last presidential administration as a very vocal critic of Barack Obama.

Republicans just defined themselves essentially as a party that was against Obama, no matter what. To me it's no accident that they ended up nominating someone who spent much of the Obama administration on television attacking Obama and even suggesting that Obama was not a real American, was not a real Christian. That was in retrospect a very effective prelude for Trump's presidential campaign, that he had been accepted by the conservative media as a conservative in good standing, as a leading critic of Obama, as someone who could deny association with any of the failure of previous Republican governance. That put him in a very good position for running against more conventional politicians, to attract enthusiastic support from conservative Republican primary voters.

In addition to that, the lack of emphasis that Republicans had placed on experience and expertise in governance – Republicans have long talked about how government should just be run like a business, that experience in government is not necessarily positive. So some of Trump's deficiencies in experience, in judgment, in knowledge — sometimes basic knowledge of political facts or the implications of policies — did not prevent him from winning the nomination and becoming president. I think it probably would have prevented an analogous Democratic candidate from getting support in the Democratic primaries. Democrats would've looked at someone like Trump and said, "He's not up to the job of being president." That didn't bother Republicans.

It strikes me that another fact about Trump points to another weakness of the GOP's conservative drift — that he offered liberal kinds of results. He offered to take care of everybody. He didn't offer any specifics, he didn't offer any explanation of how he was going to do it, but he made those promises. That also seemed to be a weakness that conservatives had created for themselves.

The conservative Republican leadership has long struggled with the gap between the American public's preference for conservatism as an abstract principle and its decidedly weaker support for specific conservative policies. Trump's solution to that dilemma during the campaign was to disassociate himself from specific conservative policies, especially on domestic economic matters. He ran as a critic of free trade. He ran as someone who would use the government power to create jobs. He ran as someone who would give you a health care plan that would cover more people than Obama, and would be better than the Democrats' health care plan. He ran as someone who would pledge not to cut Social Security, not to privatize Medicare, not to endorse any of the conservative positions on domestic social policy that have been electoral problems for previous Republican candidates like Mitt Romney.

It showed that Trump had a very shrewd sense of the fact that even among the Republican rank-and-file voters, there isn’t a lot of enthusiasm for conservative ideological policies on these issues. So he just sort of jettisoned those positions, and because he didn't have a previous record in office where he had to make those previous commitments over his political career, he could protect himself from attack on that. Democrats were left without their usual playbook of running against conservative positions on entitlement issues, especially health care.

So that helps win Trump the election, right? It helps him win some of those working-class votes in the Midwest that turned out to be so pivotal in the Electoral College. But once he took office he then, as it turned out, was poorly equipped to resist the preferences of Republican elites to pursue those conservative policies. He has people like Paul Ryan in Congress, and people like [budget director] Mick Mulvaney in his own administration, who are themselves ideologically dedicated to rollback of the welfare state. That's left him with a contradiction between the promises he made during the campaign and the positions his presidency seems to be taking on a lot of different issues. He himself has not really insisted on redirecting the trajectory of the Republican Party to be farther left on economics. He’s abandoned his own prior commitments on a host of these policies, mere months into his presidency.

So, what does that say for the immediate future? What should people pay attention to in the months ahead as the Trump administration continues to unfold -- as Republicans try to figure out what they can accomplish and Democrats try to figure out how to oppose it?

I think we should not expect much legislative productivity out of this Congress. The Republicans are really coming to terms with the difficulty of putting their ideological commitments into practice in terms of policymaking, navigating between the stringent demands of their own purist faction, and the political vulnerability perceived by their members who reside in competitive states and competitive districts. As Trump's poll numbers sag, the anxiety grows among blue and purple state Republicans that they will face a bad environment in 2018, so that's not a very fruitful situation for prolific policymaking.

At this point, there are questions about the basic competence of Republicans and governing. Will they be able to avoid a government shutdown? Will they be able to raise the debt ceiling without touching off a financial crisis? Will they be able to avoid either infuriating their own ideological base or the wider public by passing a budget and appropriating funds to domestic programs? At this point, I think any expectation of a grand conservative policy triumph probably has to be tempered. We really have to focus on whether the basic functions of government will be fulfilled without crisis or major damage incurred.

The Trump administration’s competence is, of course, an open question. But the congressional Republican Party is not a well-oiled machine either. So just focusing on Trump, and just blaming Trump for Republican troubles, is not entirely fair, and not entirely accurate as a piece of analysis. We need to consider the state of the entire party, and the problems go beyond simply the executive branch.

More questions arise when we step back to the international comparative stage and the longer cycles of history. Isn't there more to be said about how both parties are dysfunctional in different ways? If you look at welfare states in general, America is an outlier because we have a significantly smaller and less robust public sector than other liberal welfare states, nearly all of which have universal health care. Isn't that partly because of the Democratic strategy you describe of pragmatic balancing, minimal intervention in the marketplace and working within existing structures? Because that's an ideological choice. 

It's easy to focus right now on Republicans' problems with governance, and we would argue those are unique problems that come from the unique nature of the Republican Party. But of course the Democrats have problems winning elections, and in part we can trace that problem to the deficiencies or limitations of the Democratic Party, which defines itself as a coalition of social groups. The Democrats in this past election, I think, didn't realize their coalition in order to be a majority needed to contain a lot of white working-class voters, especially in certain states. So they ran a campaign that appealed strongly to some elements of their coalition — racial minorities, feminists, young people — but didn't sound economic themes very heavily that historically have helped the party gain support among working-class whites, and that I think was a serious mistake in that speaks to the weaknesses of a coalitional party. Sometimes you draw the lines around your coalition too narrowly, and I think that's what happened in 2016. So yes, both parties have strengths and weaknesses, we just think they’re different strengths and weaknesses born of the distinctive nature of each party.

With respect to the international comparison, that's a fair point you describe. The reason the Democrats are the way they are is in large part because there was never a successful socialist movement in America that firmly established the left-of-center party as grounded in an intellectual ideological tradition. When we compare the U.S. to Western Europe, that's one of the main points of difference: Socialism never took hold in the United States, the way it did in Western Europe. So that heritage is absent from Democratic Party politics, compared to labor party politics, or social-democratic party politics in Europe. That too, as you point out, has real policy implications. The Democrats have never needed to develop a common set of views about how policy is best developed and implemented.

So there's an ad hoc nature to Democratic policymaking that can sometimes result in less effective policy than a more coherent intellectual tradition might have provided. Sometimes when you make policy that’s really intended to address this anti-government critique, you wind up with policy that doesn't work as well as policy that might have been bolder and more ambitious and more confidently grounded in an alternative ideological perspective.

So the Democratic policymaking tradition is obviously not one that can claim unvarnished success over the years. There are trade-offs that are very serious that come from this asymmetry.  We do a lot of policy in this country through the tax codes, for example, that other nations would do by way of bureaucracy or through direct transmission. We do a lot of policy that is implemented at the state and local level or by private actors. as opposed to directly through the national government. That's both the legacy of our suspicion of federal power and the Republican Party's promotion of that suspicion. 

So Democrats have their own set of challenges that are profound, and they're not always been successful at navigating the demands of their own constituents and the American public in general. When you put that together with the constitutional structure, it makes it very difficult for either party to get its way, then the result is often either stasis or a kludgy set of compromises that don't really satisfy either side.

There's one other point I would make about the Republicans, that I don't think gets made enough. Another element of the position the Republicans are in now is the legacy of the George W. Bush years. Bush was not only a conservative, and the leader of the conservative movement, but during the time he was in office he also had the opportunity to govern with a Republican Congress at least for part of his administration, which previous Republican presidents going back to Eisenhower have not had.

Bush pursued a set of policies — in terms of tax policy, in terms of foreign policy, in terms of social and cultural policy — that were in some ways a fruition of many decades of conservative hopes for what would happen, and the results were ultimately poor. His presidency was ultimately a failure. The economic boom that was supposed to come from the Bush tax cuts never happened. The benefit to American power and American standing in the world that was supposed to come from an interventionist foreign policy did not happen. And even in basic governance, like hurricane relief, and certainly in its failure to prevent the economic crisis of 2008, the Bush administration was ultimately unsuccessful.

So another part of the vacuum Trump has filled in the Republican Party has been, essentially, a product of the disorientation on the conservative side about where to go after Bush, and what the true lessons of the Bush administration were. For some conservatives, the lessons were that Bush himself wasn't conservative enough. There were obviously cases where he departed from conservative doctrine, in Medicare Part D, No Child Left Behind and immigration policy, for example.

Some people took the lessons that those were the primary flaws of the Bush years, but it’s hard to make the case that those were the source of Bush's problems in office.  Those were some of Bush's most successful policy achievements. And the application of conservative doctrine in other areas didn't produce the outcomes that Bush himself had predicted and had assumed would flow from it, and the same for his supporters.

The Bush administration in some ways has faded from view because so much as happened since he was president. Trump in particular seems like such a novel development in American politics. But I think a big part of the story of the Republican Party of 2017 is the very complicated and mixed and ultimately frustrating legacy of the Bush years. The party and the conservative movement are still, I think, working through what that meant, and what the proper lessons of the Bush administration should.

By Paul Rosenberg

Paul Rosenberg is a California-based writer/activist, senior editor for Random Lengths News and columnist for Al Jazeera English. Follow him on Twitter at @PaulHRosenberg.

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