After Republicans failed to pass even a stripped down "skinny" Obamacare repeal bill to keep the legislative process alive, Senate Majority Leader Mitch McConnell, R-Ky., declared, in the wee hours of Friday morning, "it's time to move on." For now, it means that Republicans' seven-year promise to repeal and replace Obamacare has gone up in smoke. Though Obamacare was passed exclusively with Democratic support and amid fierce opposition from the GOP, there were Republicans along the way who either paved the way for its adoption, or hindered efforts to undo it. Their actions were a mix of unseriousness about policy, political cowardice, deception, ideological incoherence, and outright embrace of big government liberalism. Here is the rogues' gallery of Republicans who are most responsible for Obamacare.
Any list of Republicans responsible for Obamacare has to start with Mitt Romney. As governor of Massachusetts, Romney worked with future Obamacare architect Jonathan Gruber, the late liberal icon Ted Kennedy, and a Democratic legislature to push a universal coverage plan in the state. The law expanded Medicaid, mandated that individuals purchase a specific type of insurance, and set up an exchange on which individuals used government subsidies to purchase government-designed insurance. Sound familiar? Under Romneycare and before the adoption of Obamacare, Massachusetts had the highest insurance premiums in the nation, by far — more than double the neighboring state of Connecticut — which was a sign of things to come nationwide once Obamacare was adopted. Romneycare was used as the model for Obamacare, and his support and subsequent rise in GOP politics, allowed Democrats to sell their proposals as being less radical than they actually were.
In his two campaigns for the Republican nomination, Romney twisted himself into a pretzel trying to defend his plan, and eventually struggled to draw distinctions between the structurally similar plan that was his signature legislative accomplishment as governor and Obamacare, which he claimed to passionately oppose. His defense of his version of the individual mandate was full of deception. His nomination in 2012 ensured that Republicans would never be able to run a credible campaign against Obamacare in the final election year before the law was to be implemented. There are some "Never Trump" Republicans who may look back with fondness on Romney as representative of a more civil politics and as somebody who correctly identified Russia as America's top "geopolitical foe." But among those who care about limiting the size and scope of government, he should never be forgiven for his role as one of the founding fathers of Obamacare.
Chief Justice John Roberts
This is a controversial choice, because though Roberts served in the Reagan White House and was appointed by President George W. Bush, Supreme Court justices should not be thought of as partisan and if they are doing their jobs properly, should not rule that way. But any rogues' gallery that did not include Roberts would be missing something. In his confirmation hearings, Roberts declared, "My job is to call balls and strikes and not to pitch or bat." Yet when faced with the most significant decision of his career, Roberts became an active player, rewriting Obamacare in order to save it. After determining — correctly — that forcing individuals to purchase insurance was not constitutional under the commerce clause, he decided that this otherwise unconstitutional encroachment by government was justified just because lawmakers slapped a penalty as the enforcement mechanism. Though the penalty was not included in the revenue raising section of the law or described as a tax anywhere in the legislative text, Roberts decided to shed his umpire gear and take a swing at rewriting the law to turn the provision into a mere tax. By doing so, he split with conservatives on the court — including swing Justice Anthony Kennedy — who voted to strike down all of Obamacare, and sided with liberal justices who predictably fell in line behind their president. No matter what he does for as long as he serves on the bench, conservatives should always remember his betrayal in NFIB v. Sebelius.
Though Roberts deserves blame for saving Obamacare, there was a silver lining to his decision. Roberts was able to win over two liberal justices to agree to allow states to opt out of Obamacare's Medicaid expansion without losing all of their existing Medicaid money. This was a huge change, that allowed governors to save their states from the burden of an expanded Medicaid program, and save money for federal taxpayers as well. Holding the line on expanding Medicaid was also a huge opportunity to contain the growth of Obamacare, making it easier for Republicans to repeal the law once they gained power. Ohio Gov. John Kasich was not the only Republican governor to expand Medicaid — Vice President Mike Pence also stabbed conservatives in the back by expanding the program as governor of Indiana. But no Republican governor behaved with more brazenness and dishonesty in expanding the program than Kasich.
The former House Republican budget guru ran for governor in 2010 as a Tea Party opponent of Obamacare, declaring days before the election, "Obamacare must be blocked." But when the Supreme Court made the Medicaid expansion optional, powerful hospital lobbyists led by the Cleveland Clinic convinced Kasich to embrace the expansion so they could receive more federal money. Kasich then sanctimoniously spun his cynical betrayal of his 2010 campaign boasts in religious terms, implying conservatives who disagreed with him were bad Christians. When the Republican legislature rebuffed his plan to expand Medicaid, Kasich bypassed them to impose it on Ohio. Incredibly, Kasich went on to argue for years, with a straight face, that he supporting repealing Obamacare — even as he touted the Medicaid expansion that was a key pillar of the law and is responsible for the bulk of its spending. In a farcical incident in the fall of 2014, when it was clear he was gearing up for a presidential run, Kasich told the Associated Press of repealing Obamacare, "that's not going to happen," suggesting that opposition to the law was too ideological and that, "I don't think that holds water against real flesh and blood and real improvements in people's lives." Kasich then went on Twitter to rant and rave about the story, saying, "the AP screwed up. Let me make my position simple. Repeal Obamacare."
During the past six months, Kasich has served more as a lobbyist to preserve Obamacare, joining with Democratic governors to fight Medicaid changes and push for more federal handouts. He has opposed each version of repeal and pushed Sen. Rob Portman, R-Ohio, into an ideological warrior for the Medicaid expansion, making it more difficult to hash out any sort of compromise.
George W. Bush
Bush's presidency pre-dated Obamacare's adoption, so his inclusion on the list may not be quite obvious. But he was responsible, both in direct and indirect ways, for the law. One of the strongest arguments Democrats had during the 2009-2010 legislative push on Obamacare was that Republicans didn't do anything to address the very real problems of healthcare costs when they were in power. This argument had the benefit of being true. Republicans, historically, have tended to be much more passionate about opposing Democratic efforts to expand healthcare coverage than they are about offering their own solutions. Republicans were quite fired up about healthcare in 1993 and 1994, when they were fighting back the Clinton healthcare push. But once they defeated the bill, they went largely into hibernation on the issue. As Democrats studied the lessons of the Clinton bill's failures, and planned for their next chance to pass something, Republicans largely moved on. President Bush's big healthcare policy was including health savings accounts in a Medicare prescription drug bill that represented the largest expansion of entitlements since the Great Society. But Bush didn't offer a plan to address the broader market until 2007, by which point it was too late because he was a lame duck and Democrats had already retaken Congress. Under an alternate scenario in which Republicans used the Clinton era defeat to come up with ways to reform the system, they could have used free market policies to expand insurance in the individual market. This would have given free market solutions a chance to work, and communicated that Republicans have a positive healthcare agenda. Aside from the lost opportunity, Bush's catastrophic handling of the Iraq War and other failures, drove down his approval rating so low, that Democrats were able to swamp Republicans in two consecutive elections and amass the filibuster-proof Senate majority that enabled them to deliver Obamacare.
Republican congressional leaders since 2010
The reason why Republicans had so much problem coming up with a compromise proposal to repeal and replace Obamacare is that they didn't lay the foundation when they were out of power and had plenty of time. Healthcare divisions among Republicans have always been an issue, but instead of doing the hard work of hashing them out, the GOP instead decided to focus on scoring short-term messaging victories. Negotiating about Medicaid growth rates, unraveling the interlocking web of regulations, and determining subsidy levels and design, is hard work. But it's easy to unite Republicans around complaining about whatever is in the headlines on a given day — higher premiums, higher deductibles, Medicare cuts, failing insurers, and so on. So, "repeal and replace" became an easy dodge for Republicans.
The inability to focus on developing an alternative has to lie with the Republican leaders since 2010 — John Boehner, Eric Cantor, Mitch McConnell, and more recently, House Speaker Paul Ryan, R-Wis. Boehner, Cantor, and McConnell pioneered the disingenuous pledges to repeal Obamacare: running on repealing Obamacare in 2010 only to say they needed the Senate to repeal it; winning control of the Senate in 2014 only to say they needed the presidency; winning the presidency and then finally revealing that repeal didn't have the support to pass. Cantor, now safely in an investment firm, revealed in a Washingtonian interview this week that he didn't actually believe they'd be able to repeal it, but was afraid to say anything, or else it would have been more difficult to exploit opposition to the law. "[I]f you've got that anger working for you, you're gonna let it be," he said. Ryan was a special case in that as a lone member of Congress, he did propose healthcare alternatives, including one of the bills that was introduced as an alternative to Obamacare while it was still being debated. But as he moved up the leadership ranks, his rhetoric about wanting to advance a serious policy agenda has not translated into reality. The "Better Way" healthcare proposal that Ryan released last year was more of a brochure, and there was no broad consensus built for it, as demonstrated by the House struggles to narrowly pass legislation. But Ryan, along with McConnell, deserves additional criticism for pursuing an insane process meant to rush through a healthcare bill without taking the time to go through the normal committee process, properly debate the legislation amongst each other and hear from experts. Despite his past life as a policy entrepreneur, Ryan failed to articulate an overarching vision for healthcare.
The biggest barriers to passing a repeal bill were so-called moderates who had difficulty articulating what parts of Obamacare they actually didn't like. Throughout the discussions in both the House and Senate, whenever conservatives made concessions, centrists moved the goal posts, demanding more taxes and spending, and fighting to preserve core Obamacare regulations that make it impossible to create a coherent replacement. Of all the cynical lawmakers involved in the process, none deserve more scorn than the six senators who voted in 2015 to repeal the law's major tax and spending provisions when they knew Obama would veto the bill, only to oppose it this time around because it actually had a chance of becoming law. Those senators were: Lamar Alexander of Tennessee, Shelley Moore Capito of West Virginia, Rob Portman of Ohio, Dean Heller of Nevada, Lisa Murkowski of Alaska, and John McCain of Arizona.
A few weeks ago, I wrote a column titled, "Don't blame Donald Trump for Republican healthcare woes" — and I stand by it. As I detailed above, Republican problems on healthcare predate Trump and they are more fundamental. His success in the Republican primaries despite his incoherence, if anything, is a reflection of the lack of seriousness with which voters care about policy details. The primary responsibility for the failure of repeal and replace has to lie with Republican members of Congress, because Trump would have signed anything they passed. So, while Trump's actions didn't kill the healthcare bill, he certainly didn't act effectively as an executive to guide the process across the finish line. His failure to grasp basic policy details made it more difficult for him to win over skeptical lawmakers, because he doesn't understand what their ultimate asks are. As a result, many lawmakers left discussions and meetings with Trump convinced he was with them on a particular policy preference, even though that policy preference was directly opposed to a policy preference he agreed to with another lawmaker.
The impression of a White House in chaos, Trump launching a public attack against his own Attorney General Jeff Sessions, and a new communications director in open war with the chief of staff and senior White House adviser, just as healthcare was making its way to the finish line in the Senate, is not conducive to the president being able to play a helpful role in the process. The absence of Trump would not have magically solved Republicans problems dealing in a Senate where the ideological gulf spans Sen. Susan Collins of Maine, who wanted to largely keep Obamacare in place, and Sen. Rand Paul of Kentucky, who wanted to see it fully repealed and replaced with a free market alternative. But he certainly did not help in the way a knowledgeable and emotionally stable president might have.