On Health Care, Republicans Care About Politics, Not Policy

Do Republicans care about health policy at all? Not really, at least judging by the party's twenty-plus year history of erratic and contradictory interest in health care legislation. That's basically the point that both Jonathan Chait and Josh Barro make in separate pieces today, and also part of the point I tried to make a few weeks ago when I argued that GOP support for the individual mandate was never terribly strong.

Republican legislators weren't actually interested in health policy, but they were interested in saying they had a health policy. That's why a number of them nodded along when the Heritage foundation proposed the individual mandate. For the most part, Republican interest in health policy coincided neatly with political convenience. Republicans opposed Clinton's health care plan because they thought it was politically advantageous. They whipped votes in favor of an unpaid-for expansion of Medicare drug coverage in large part because they didn't want Democrats to get credit for having passed something similar (it helped that their version was approved by the pharmaceutical industry). And during the years when they controlled the White House and both houses in Congress, they didn't pursue structural reforms to the existing Medicare entitlement or the larger health insurance market because they didn't see a political advantage in doing so. When Mitt Romney passed a health policy overhaul in Massachusetts, a number of Republican legislators voiced their support—not because they cared about the details of the plan, but because they thought it would check off the health policy box, and because they thought there was a political advantage in wielding the plan against Democrats.

However, there have always been pockets of GOP support for doing something about health care, or at least for being seen to do something. Which is why I think Chait is at least misleading when he writes that "Republicans have never appropriated any money to cover the uninsured." Rather than look at appropriations, it's better to look at whether Republican legislators have ever voted for plans that expanded health insurance coverage. And at both the federal and the state level, some Republicans have. Republicans have voted to create state-managed high risk insurance pools. And in the late 1990s, GOP Sen. Orrin Hatch helped create the State Children's Health Insurance Program (SCHIP). Many of his fellow Republicans voted for the bill that created it. In 2007, Republicans reauthorized the program by voice vote, and in 2009, 40 House Republicans and nine Senate Republicans joined Democrats to support extending and expanding the program—an expansion that President Bush had opposed but that President Obama signed into law.For at least the last two decades, health policy has not been a core part of the Republican party's identity. Taking advantage of health policy debates to score short-term political points has. Which is why, despite early promises to have an ObamaCare alternative ready by the summer, Republicans on Capitol Hill gave up working on a legislative alternative. Overall, the party's elected official care more about the political advantage of opposing ObamaCare than they do about sinking effort and political capital into crafting workable legislative alternatives. 

But even the SCHIP votes show how weak GOP support has historically for any particular health policy idea: A majority of Republicans voted in favor of the legislation that created the program when they thought there was a political advantage to doing so, and a little over a decade later, a majority of Republicans voted against it.

I would like to think that the last few years, during which it has been impossible for GOP legislators to avoid thinking about health policy, have changed things somewhat. Clearly there are a handful of GOP elected officials with wonkier backgrounds—people like Rep. Paul Ryan and Louisiana Gov. Bobby Jindal—who do care about the details of health policy. But there's no larger party effort to either craft plans or do the long-term work of building the coalitions to support them. The party's House and Senate leadership are sticking with a strictly political message of opposing the current president's policies and the party's presidential candidate seems content to run on non-specific Obama opposition fake policy plans. Which is why I remain skeptical. If the bulk of the GOP cared about health care policy, as opposed to health care politics, they would have shown it by now.