he Senate’s recent failure to repeal the Affordable Care Act (ACA) makes replacing it with a market-friendly alternative even more difficult and less likely. Failure by Congress to undo the mistake of 2010 will bring a raft of negative consequences: obvious and concealed; in the near and distant future.
The obvious, immediate, political consequence will be for Republican and independent conservative voters to become even more skeptical about the value of electing Republican officeholders. The picture they see today is this: A Republican Senate voted to repeal Obamacare in 2015 when a Democratic president’s certain veto rendered this legislative act a gesture. When it mattered, however, with a Republican president ready to sign repeal-and-replace legislation into law, the Republicans could no longer find the votes. If a new picture is not drawn soon, this combination of cynicism and fecklessness will embolden the Left and dispirit the Right in ways that could lead to Republican defeats in November 2018 and beyond.
And yet precisely because so many commentators are treating this scenario as a foregone conclusion, some perspective is needed. For one thing, this moment in health care is not a purely partisan failure. Democrats were entirely responsible for enacting Obamacare in 2010, and in 2017 almost all Republicans voted to repeal it while every single Democrat voted to preserve this increasingly unsustainable program. If the curse of one party is that it has been unable to do necessary things by uniting, the curse of the other is its solidarity on behalf of pernicious things. Moreover, the electoral backlash against sins of omission is often less severe than against ones of commission.
For all that, Republican leaders will be living very dangerously if they invest too much hope in these mitigating considerations. A GOP base whose mood ranges from disaffected to livid poses serious dangers for the midterm elections.
The policy consequences of failing to repeal ACA are less conjectural. One of the most ill-conceived and authoritarian pieces of legislation enacted in the last 100 years will be left standing, despite the havoc it is wreaking on the health care system. Taxes and regulation will be higher than necessary, job-killing mandates will remain. More doctors will leave the system, costs will continue to rise, more Americans will confront fewer choices among insurers, and the entire private insurance system will careen toward disaster.
In the longer term, the failure by this GOP Congress to adopt a free-market alternative vastly increases the odds that a fully government-run health system will be America’s ultimate, inescapable fate. The worse-than-useless Congressional Budget Office forecasts are based on the illusion that Obamacare, as it currently exists, is sustainable enough to cover anyone ten years from now. The real choice has never been between ACA and a conservative reform, but between a conservative reform and the collapse of private health insurance. The latter development could well create irresistible financial and political pressure for single-payer health insurance—“Medicare for all”—the Democrats’ Holy Grail and ultimate health care aim since Harry Truman.
A cynic might suggest that this was the Democrats’ real aim in 2010. Whether intended or not, it is the path on which the ACA has placed us. Bernie Sanders’ recent announcement that he will soon introduce a single-payer bill will not affect the course of policy under this Congress and president, but previews the next decade’s health care debate. Ultimately, government control of health care cannot mean anything other than government control over well-being, indeed over life and death, on an everyday basis. Many Charlie Gards will be in our future.
More broadly, failure to repeal ACA could mark the end of any meaningful attempt to retain and restore limited constitutional government. Tocqueville’s democratic despotism will advance on all fronts, and the entitlement crisis that threatens the republic’s solvency will advance with it. We are, of course, well down this road already, but repeal of the ACA provides a rare, hugely significant opportunity to reverse course. If we cannot undo a policy in operation for only three years, benefitting 5% of the American people at the expense of many more, then the failure and abandonment of our experiment in self-government becomes that much more likely, and proximate. The failure to date is a textbook demonstration of why we have a $20 trillion debt. The Greeks, at least, could assign some blame for their fiscal and governmental debacle to the European Union and its imprudent experiment in a multinational currency. Americans, who control their own currency, will have no other culprits for the collapse of their republic.
Most obscured and least commented upon, though far from least important, are the Obamacare debate’s international stakes. Europe depends on the United States for defense largely because its welfare states have swallowed up available public resources. All else being equal, it is almost always politically easier to cut defense spending than the social programs of clients who demand their benefits’ perpetual continuation and expansion. But when the United States has a European-sized welfare state, with government-run health care that crowds out defense expenditures, which country will be our America? When we too, like almost every European country, are spending less than 2% of GDP on defense because we cannot afford our own “free” health care, who will gain? It is ironic that the same voices concerned (suddenly, since late 2016) about Russian influence are demanding health care policies that virtually guarantee that Russian and Chinese influence in the world will grow at the expense of the U.S. and its allies. This is the collusion no one talks about.
It might be objected that this picture is too bleak. Unforeseen events may intervene, and no one doubts that the current administration can make many regulatory changes that might limit some of ACA’s worst features even without new legislation. But if no alternative repeals and replaces Obamacare, the next Democratic president (perhaps in 2021) can use the resulting chaos to push for single-payer. Indeed, if President Trump makes good on his promise to eviscerate the ACA through administrative action without a real legislative fix, he might accelerate the drive toward single-payer. In less dire scenarios, we may just limp along, enduring a destructive system because nothing else can gain enough traction to be enacted. Obamacare will survive through ever-increasing government subsidies, every state will eventually assent to Medicaid expansion, quality and choice will diminish, and rationing will become inevitable. The ultimate consequences of staying in the frying pan of Obamacare will not be much different than jumping into the fire of single payer.
The latest whispers from Washington are that Republicans will try again to fashion a plan that can get 51 Senate votes. With a fractured party, a united opposition, a hostile media, and a president struggling to provide legislative leadership or articulate a public argument, no one should bet on success. On the other hand, the consequences of failure make success necessary. And necessity is the mother of invention.
The stakes are large indeed, and, so far, Republicans and Democrats have both failed the country. How, and whether, they can redeem themselves at this late hour are questions with no clear answers.
Andrew E. Busch is a Professor of Political Science at Claremont McKenna College. For more information, click here.