On January 19, 2011, in one of their very first actions after retaking majority control of the House of Representatives, Republicans voted to repeal the Patient Protection and Affordable Care Act, a.k.a. Obamacare. The vote was largely symbolic; no one expected the Democratic Senate to take up the measure. But for the House GOP, the repeal vote was the necessary fulfillment of the core campaign promise that helped sweep them back into power.
That promise, however, was only half fulfilled. Republicans had not merely vowed to remove Obamacare; they also said they would pass a program of their own in its stead. "Repeal and replace" was the mantra, and work on the second half of that slogan was to begin immediately. "We want to repeal today so that we can begin to replace tomorrow," Rep. Joe Barton (R-Texas) told The New York Times.
A consortium of House committees would be instructed "to begin work to construct an alternative health care vision" and create a "so-called replacement bill," Majority Leader Eric Cantor (R-Va.) told reporters. No specific timelines were laid out, but House Speaker John Boehner (R-Ohio) told the press that it would not be a drawn out process. "We expect them to act in an efficient way."
A year later, no replacement plan had surfaced. Republicans continued to insist optimistically that one was on the way. In January 2012, Rep. Joe Pitts (R-Pa.), head of the Energy and Commerce Committee, told a group of reporters that when the health law was adjudicated at the Supreme Court that summer, the GOP would have an alternative set to go. "We will be ready to respond to the Supreme Court decision, which is expected in June, with a replacement package," Pitts predicted. "We think that a free-market alternative is much better as far as making health insurance affordable and available to everyone."
The Supreme Court decision came and went; Obamacare survived. Republicans remained stuck on the first half of their repeal-and-replace pitch. The initial vote to get rid of the Affordable Care Act was followed by dozens more, each just as symbolic as the first. By August 2013, House Republicans had voted for repeal 40 times.
Obamacare's most consequential provisions -the health insurance exchanges and regulations on pre-existing conditions-were now about to take effect. As the October opening of the exchanges neared, congressional Republicans, at the urging of conservative activists, settled on an unlikely last-ditch gambit to stop the hated law: insisting that any measure to provide funding to keep the government open must not include funding for Obamacare.
The gambit failed, and it did so predictably. On October 1, the government shut down and the health-plan exchanges opened for business, spotty as they were. The shutdown ended two weeks later, leaving the Republican Party badly bruised in the polls and conservative activists at each other's throats over who was to blame. Far from uniting around an alternative, the GOP and its conservative base had split over the one health policy idea that was supposed to unite them all: taking down Obamacare.
For conservatives and for GOP legislators on Capitol Hill, the advent of the Affordable Care Act could have inspired a reckoning, a rethinking of how to lay the public groundwork for a post-Obamacare future. Instead, even as the ACA rollout fell on its face (see "They Lied," page 22), erasing the GOP's shutdown-triggered poll drop and battering President Barack Obama's approval ratings, uncomfortable questions remained: Is there a coherent Republican health policy? Is such a thing even possible in today's climate? Or is the political right only effective at saying the word "no"?
Looking for a Health Care Theory
The GOP's staunch opposition to Obamacare, combined with its unfulfilled promise of a replacement, has opened up the party to years of criticism that it has no health care ideas at all. In 2009, as the law was working its way through Congress, Obama accused Republicans of simply wanting to preserve the status quo. "I've got a question for them," he said. "What's your answer? What's your solution? The truth is, they don't have one. It's do nothing."
Democrats repeated similar attacks long after the law passed, and some Republicans even agreed. In August 2013, former House Speaker Newt Gingrich said at a meeting of the Republican National Committee, "I will bet you, for most of you, you go home in the next two weeks when your members of Congress are home, and you look them in the eye and you say, 'What is your positive replacement for Obamacare?' They will have zero answer."
It's not quite true that conservatives have no health policy ideas. On the day they first voted to repeal Obamacare, Republican legislators off-handedly mentioned numerous possibilities -high-risk pools for the very sick, allowing the purchase of insurance across state lines, reducing coverage mandates to make health plans cheaper-that might be part of a future alternative. Many of those ideas are still floating around the party's policy byways today, waiting to be tethered to a specific proposal.
What Republicans don't have is a theory-a broadly shared vision of how health care ought to be delivered in America. Without such a shared understanding, one that can be easily and succinctly described by politicians and activists alike, it's hard to unite around, or even talk about, any particular plan. The result is that many Republicans would rather discuss the specifics of Obamacare's failings while presenting their alternative ideas in catch-phrase generalities like "patient-centered care," "affordability," and "preserving the doctor-patient relationship."
That's not to say that no one is advancing alternative principles for reform. A handful of conservatives, libertarians, and even some elected Republicans have proposed a variety of plans and principles in recent years. Their suggestions feature varying degrees of complicated details and secondary priorities, but most of them revolve around the central idea of uprooting the tax system's existing preference for individual insurance by reforming the tax treatment of health benefits.
Some proposals, like the one put forth by Cato Institute Health Policy Director Michael Cannon, focus heavily on clearing the health system's existing thicket of regulations and subsidies to create much more individual autonomy throughout the market. In a 2009 paper, "Yes, Mr. President: A Free Market Can Fix Health Care," Cannon laid out a plan for converting Medicare into a voucher system (he now favors Social Security-style direct payments to enrollees), ending state-based monopolies on both insurance and clinician licensing, capping federal spending on Medicaid through block grants, and eliminating the tax preference for employer-sponsored health care.