The Republican health bill is stuck in a valley of incoherence

On Thursday, Sen. John Cornyn, the Texan who serves as Mitch McConnell’s second in command, offered a dazzling display of the GOP’s incoherence on the goals of health care policy.

He was discussing the Congressional Budget Office’s finding that 22 million fewer people would have health insurance under the Better Care Reconciliation Act. Most Republicans have treated the estimate as a disaster — its release threw the bill into a political tailspin from which it has yet to recover. But Cornyn had a different interpretation. Those 22 million people, he tweeted, weren’t going to “lose” health insurance; they were going to “choose” to go without it. All the CBO had certified, he suggested, was that the bill increased freedom:

In Cornyn’s telling, if a family making $16,000 a year decides there’s no point to buying a plan with a $6,000 deductible because insurance doesn’t help you if you can’t afford to use it, they’re just showing they didn’t really value health insurance in the first place:

A sitting US senator celebrating Americans’ freedom to not be able to afford health insurance sounds like a socialist satire of American values. But it also exposes the deepest problem afflicting the GOP’s health care effort: There is no clarity within the Republican Party on what its health bill is meant to achieve. Top Republicans can’t even agree on whether de-insuring tens of millions of people is a moral failing or a bold advance for freedom!

Take the CBO reports that have battered the House and Senate plans. We have learned, through trial and error, that most Republicans — though not all! — think a CBO report showing an increase of at least 22 million in the uninsured population is bad. But what would a good CBO report look like? Would a 15 million increase in the uninsured population count? Ten million? Five million? Does the number of Americans with insurance matter at all? Is the real measure of success premiums — and if so, premiums for whom? Or is it really deficit reduction? Or tax cuts? Or regulatory burden? Or is it just getting to 51 votes for something that can be called repeal and replace?

Political parties tend to agree on the goals of their major legislative efforts even if they disagree on means. The GOP’s various tax reform efforts begin from the premise that taxes should be lower. The Democratic Party’s health care push began with the premise that there should be fewer uninsured people. The fight over how best to achieve those goals was fierce, but everyone was clear about what they were trying to achieve, and so it was clear how to evaluate different policies.

That’s not the case here. The GOP’s health care effort began with the premise that Obamacare is bad and must be repealed and replaced. But repeal and replace is a means to an end, not an end itself. The end, in theory, is the post-replacement health care system — a system that aligns with the GOP’s vision of how health care should work. But that vision is absent. When we asked eight Republican senators to tell us what the health bill was meant to achieve, we got eight different answers, and most of them were incoherent.

The GOP’s lack of conviction on health care policy has proven a political advantage in recent years, as it’s allowed them to criticize Obamacare opportunistically, rather than binding them to attacks that aligned with their health care policies. That’s how you got Donald Trump promising to cover everyone and McConnell complaining about the law’s high deductibles. Cornyn, for his part, was criticizing Obamacare for leaving 28 million people uninsured just a few days ago. (At least, I think he was criticizing it. Maybe he was praising the small measure of liberty it left to those Americans? It’s hard to tell.)

Now, however, a Republican Party that only knows what it is against has to decide what it’s for — and it’s failing. The result is a chaotic legislative process wherein no one knows how to evaluate the proposed policies except on the crudest tactical dimension. Bills are unveiled and amendments offered wherein the only evident goal is getting something passed. At times, Republicans have been shockingly honest about this. Asked what problems the bill was meant to solve, Sen. John McCain replied, “They’re trying to get to 51 votes.”

I recently had Avik Roy on my podcast to discuss the Senate’s health bill. Roy, the co-founder of the Foundation for Research on Equal Opportunity and an influential Republican voice on health policy, has said the BCRA’s passage would be "the greatest policy achievement by a GOP Congress in my lifetime.” But our conversation quickly revealed a more complicated view. Roy agreed with many of the criticisms of the bill, and was quick to admit that, as designed, it priced insurance beyond the means of the people the plan is meant to help. (He has offered suggestions for improving it here.)

Roy’s enthusiasm for the bill, I came to understand, revolved around its role in the long-running internal GOP argument over health care. To Roy, the BCRA shows the Republican Party is shifting from a political coalition that opposes efforts to build a universal health care system to a political coalition that is trying to build one itself. GOP leadership is proposing legislation that creates income-based tax credits to subsidize health insurance for the poor — isn’t that progress worth celebrating?

But the party’s transformation is glaringly incomplete. Yes, the law’s tax credits could provide the structure for a universal health care system, but the law doesn’t have nearly enough funding to actually achieve that goal. Roy is confident that they’ll fix that problem. But so long as top Republicans like Cornyn don’t believe it’s a problem at all, I am confident he’s wrong.

McConnell is trying to find a compromise between the wing of his party that wants to cover the poor and the wing of his party that doesn’t; between Republicans who think a 22 million increase in the number of uninsured Americans is a moral blight and those who think it’s a win for freedom. There is no sensible policy that splits the difference between perfectly opposed goals. And so the Kentucky Republican, in his purely tactical way, has found a compromise: a bill that could cover the poor, but won’t.

This is what happens when you make policy from deep inside a valley of incoherence. You mistake means for ends, you find yourself crafting policies with no clear sense of what they’re meant to achieve, you mistake something that might pass for something that will work. Aside from being able to say they repealed and replaced Obamacare, Republicans don’t know what they want their bill to achieve, and so at this point, it doesn’t achieve anything, save cutting taxes.

A lesson of the Affordable Care Act is that health care policy is hard to get right even when it’s thoughtfully designed and backed by a party deeply committed to its success. The Obama administration knew exactly what it was trying to achieve, was filled with health care experts who had spent decades thinking about how to achieve it, and it still got the Healthcare.gov fiasco, and some unstable individual markets, and premiums it couldn’t control.

The BCRA, by contrast, is poorly designed, backed by a party that does not share a single definition of success, and will be implemented by an administration that is chaotic on its best days. It’s a disaster in the making.

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