Long before Donald Trump’s second-place finish somehow landed him in the White House, Republicans in Congress promised a package of benefit cuts, privatization, and tax cuts for the wealthy that were so cruel, American voters literally refused to believe they were real. In 2012, a Democratic super PAC decided not to campaign against future Speaker Paul Ryan’s package of Medicare vouchers and upper income tax cuts after participants in a focus group “simply refused to believe any politician would do such a thing.”
Under the Republican Party’s Medicare plan, seniors’ out-of-pocket health costs would literally double. Some of their plans cut Medicaid spending on poor people’s health care in half — and then slashed even deeper in later years. The GOP would have even kicked 1.5 million people off of food stamps, leaving many families hungry while the wealthiest Americans suckle at the teat of Donald Trump’s tax cuts.
Two years later, the Trump administration remains cruel, racist, and deeply corrupt. Yet its saving grace — and that of its Republican allies in Congress — is that it is so bumblingly incompetent, the GOP’s toxic legislative agenda never really got off the ground. Rich people got their tax cuts (a gimme during any period when Republicans control Congress and the White House), but the wholesale overhaul of the welfare state that Ryan’s dreamed about since he was “drinking at a keg” never manifested.
Republicans squandered their best chance to ravage poor people the way they’ve always wanted. And with incoming Speaker Nancy Pelosi taking up her gavel on Thursday, they will not get another chance for at least another two years.
Sadism flavored with malevolence
The GOP’s plans for America’s health care system were literally unbelievable to many Americans, but they were very real at the end of 2016, and they appeared destined to become law.
Midway through 2016, Speaker Paul Ryan released “A Better Way,” a medium-sized white paper laying out his plans to dismantle much of the American state. As the Huffington Post’s Jonathan Cohn and Jeffrey Young quipped, Ryan planned to “replace 20 million people’s health insurance with 37 pages of talking points.”
Yet, if anything, Cohn and Young were too kind to Ryan. The two reporters based their claim that 20 million people would lose health insurance off of a 2015 Congressional Budget Office (CBO) report estimating that 19 million people would lose insurance in the first year if Obamacare was repealed — a number which would continue to grow in subsequent years. But Ryan’s plans were far more ambitious than simply turning the clock back to 2008, before an African-American family moved into the White House and dared to deliver affordable health coverage to the uninsured.
Ryan’s signature proposal — replacing Medicare with a voucher that seniors could use to buy private plans — was a centerpiece of A Better Way. The 2016 version of Ryancare was short on numbers and long on lofty rhetoric, so it’s difficult to state with precision just how much it would hurt seniors. But Ryan’s plan to shift many seniors into private health plans would have driven up health costs for two reasons. Private plans have “substantially higher administrative expenses than traditional Medicare,” and they are “not able to negotiate comparably low provider payment rates, that is the rates that are paid to doctors and hospitals, as is traditional Medicare.”
Indeed, an earlier version of Ryan’s voucher proposal, according to the CBO, would have doubled seniors’ out-of-pocket costs.
Medicare beneficiaries, however, got off relatively easily under the GOP’s proposals. The biggest victims would have been poor people and other Medicaid beneficiaries — including many seniors who require long-term care.
A Better Way’s Medicaid proposals were complex, but the short version is that it gave each state a choice between two options. The first opinion would have cut overall Medicaid spending by about a third. The other “would require cuts to federal Medicaid funding per beneficiary of about 50 percent by the tenth year.”
Legislating in a bubble
The GOP’s plans to gut America’s health care safety net were, if nothing else, some of the most ambitious proposals to arrive in Congress since the Great Society. So one might reasonably expect Republicans to seek out allies who could help ease these proposals into passage.
As President Obama learned during his own fight to overhaul much of the nation’s health care system, passing major legislation is difficult even when you have supermajorities in Congress and an array of interest groups on your side. And yet Republicans managed to alienate nearly everyone in the health care industry and several of their own senators to boot.
By 2017, when the GOP took control of all three branches of government, opposition to Obamacare was central to the Republican Party’s identity — legislators had already tried to repeal the law more than 60 times up to that point. It is reasonably likely that, if the GOP had limited its health proposals to rolling back provisions of the Affordable Care Act, they could have scraped together enough votes to pass a bill into law. Instead they got greedy, adding big Medicaid cuts on top of their attacks on Obamacare.
That was too much for Sen. Susan Collins (R-ME), one of three Republican senators who ultimately opposed the GOP’s health bills. “You can’t take more than $700 billion out of the Medicaid program,” Collins said in a July 2017 interview, “and not think that it’s going to have some kind of effect.” A few months later, when Republicans tried to revive their proposals in a slightly different form, Collins warned that their Medicaid cuts “would have a devastating impact to a program that has been on the books for fifty years.”
But Republicans didn’t just alienate crucial senators, they also wouldn’t bargain with the major health industry groups that, in the past, had the power to sink major health care legislation. The result was that pretty much everyone with a stake in the health care industry opposed the GOP’s bills.
The American Medical Association warned that one version of Trumpcare “would result in millions of Americans losing coverage and benefits.” The American Hospital Association warned that the bill’s harsh Medicaid cuts “will have serious negative consequences for communities across America.” AARP said that the bill would “weaken Medicare’s fiscal sustainability, dramatically increase health care costs for Americans aged 50-64 and put at risk the health care of millions of children and adults with disabilities, and poor seniors who depend on the Medicaid program for long-term services and supports and other benefits.”
Even America’s Health Insurance Plans, the lobbying group for the health insurance industry, warned that the bill’s Medicaid cuts “could result in unnecessary disruptions in the coverage and care beneficiaries depend on.”
To be sure, all of these groups acted out of pure self-interest when they opposed the bill. As I wrote at the time,
Doctors stand to lose patents if millions of Americans lose coverage or wind up on inferior plans. Many hospitals restructured their business models to account for the Affordable Care Act, and would need to make more costly changes if the law were significantly altered. AARP is a membership organization representing older Americans, who are likely to face the greatest financial burdens if the House bill becomes law. AHIP obviously doesn’t want to see its own markets destabilized.
But the fact that these groups are self-interested — or in some cases driven almost entirely by a profit motive — does not mean that their concerns can be ignored.
It is impolitic, to say the least, to suggest that health insurers and wealthy hospitals must be at the table when a health reforms are being designed. But there’s a profoundly practical reason why lawmakers must speak to industry groups before moving forward with legislation. Health industry players know a lot about how health markets actually work. And lawmakers need to know this information if they don’t want to do more harm than good.
You don’t have to like health insurance companies, for example, to recognize that an adverse selection death spiral would be bad for patients. Nor do you have to be sympathetic to overpaid health providers to recognize it would be a disaster if Congress forced medical centers to change their business models so quickly that many rural hospitals would simply shut down.
Congress should not legislate in the interest of industry groups. But it does need to live in the real world, and that means finding ways to work around legitimate problems that arise every time lawmakers undertake major reforms.
Republicans, however, thought they could rely almost entirely on the advice of ideological groups with no real stake in the health care industry. There’s a deep irony underlying the fact that the Republican Party, long thought to be in the pocket of big business, wouldn’t even listen to health industry groups telling them that their proposals would end in disaster. But that’s what happened, and it meant that many of these groups worked to keep wavering lawmakers from supporting Trumpcare.
The man who couldn’t do math
Let us now pause to consider the unique incompetence of outgoing Speaker Paul Ryan.
you know what episode really encapsulates Paul Ryan's career?
the time he tried to fire the House Chaplain for praying the tax bill wouldn't hurt poor people – only to cave under pressure from other Rs & reinstate him.
— Jesse Lehrich (@JesseLehrich) December 20, 2018
In November of 2017, when the House was debating the Trump tax cuts, House Chaplain Patrick Conroy delivered a largely unnoticed prayer. “May all members be mindful that the institutions and structures of our great nation guarantee the opportunities that have allowed some to achieve great success, while others continue to struggle,” Father Conroy, a Jesuit priest, told the House. “May their efforts these days guarantee that there are not winners and losers under new tax laws, but benefits balanced and shared by all Americans.”
Had Speaker Ryan simply let this prayer pass, barely anyone would have known about Conroy’s act of resistance. Instead, Ryan abruptly told Father Conroy to resign last April, and without citing a reason why. To make matters worse, Ryan’s chief of staff later gave a few reasons why Conroy was targeted. One was Conroy’s prayer. Conroy also says that chief of staff Jonathan Burks told him that “maybe it’s time that we had a chaplain that wasn’t a Catholic” (Ryan is a Roman Catholic).
The result was that news of Conroy’s defiant prayer spread faster than you can say the words “Streisand effect.” Ryan eventually decided that he had to reinstate Father Conroy.
Obamacare is alive, and Ryan’s political career is dead.
Ryan’s vindictive attack on the Jesuit priest, combined with his chief of staff’s reported anti-Catholic remark, captures the pervasive incompetence Ryan brought to the House of Representatives. Indeed no one, not even Donald Trump, embodies the stew of hucksterism, rigid ideology, dyscalculia, and superficial charm that drives the Republican Party more perfectly than Paul Ryan.
Ryan is allergic to arithmetic. In 2005, Ryan proposed a Social Security privatization plan that was so aggressive, it would have eventually required the Social Security Administration to buy up “every single stock or bond in the United States” — unintentionally transforming the United States into a communist nation. An early version of Ryan’s Medicare vouchers would have slowly phased out Medicare in its entirety, though Ryan eventually dialed back this effect after his proposal was widely derided.
For years, Ryan’s tax proposals depended on a multi-trillion dollar “magic asterisk” to control deficits. The tax bill Ryan actually helped pass in 2017 contained no such magic, and wound up increasing the annual deficit by $343 billion over what it was before Ryan became speaker.
Ryan owes his swift advancement to the House’s highest job to his ability to con reporters into thinking he was some kind of policy wonk. The future speaker dazzled non-wonks with a blizzard of charts, white papers, and impressive-seeming numbers. But his numbers never added up. And the only major legislation he passed as speaker proves as much. You can’t balance the budget with a magic asterisk.
It’s a fitting coda to Ryan’s undistinguished career that he leaves amidst a government shutdown triggered by his own ineptitude. The Senate unanimously passed legislation keeping the government open after the White House indicated it would support this bill even if it did not include money for Trump’s Mexican border wall. When Trump abruptly changed his mind, Ryan could have forced the bill through the House and rallied his caucus to override Trump’s veto.
Instead, Ryan didn’t even have the courage to stand up to Trump just a few weeks before Ryan retires. Even with nothing to lose, Ryan still could not find his spine.
The looming catastrophe
So Republicans lose control of Congress with little to show for it. The Randian revolution Paul Ryan promised his donors never manifested. Obamacare is alive, and Ryan’s political career is dead.
Yet, while Republicans won’t be able to push a legislative agenda for at least the next two years, that doesn’t necessarily mean that their incompetent lawmaking operation will prevent the nation from becoming a Tea Party dystopia.
Neil Gorsuch, as I’ve written, “combines the harsh ideology of Justice Clarence Thomas with the smug self-righteousness of the Mayor from Buffy the Vampire Slayer.” Brett Kavanaugh is a longtime Republican operative who appeared to threaten revenge — “what goes around comes around” — against Democratic senators who probed credible allegations that a teenage Kavanaugh tried to rape future psychology professor Christine Blasey Ford.
Trump is an ignoramus and a goon, but his judicial nominees are some of the smartest and most radical attorneys in the nation. And, barring truly extraordinary events, Republicans will still control the Senate — and the ability to confirm Trump’s judges — for the remainder of Trump’s term.
Last month, a Republican former Senate staffer named Reed O’Connor handed down a laughably weak judicial opinion striking down the entire Affordable Care Act. Trump is stacking the bench with more Reed O’Connors. It’s likely that he already put two of them on the Supreme Court.
So, while Republicans appear unable to pass legislation even when everything is stacked in their favor, they may not need to. The legislative threat to the New Deal, the Great Society, and Obamacare is now dormant. But you don’t need to control Congress if you can fill the judiciary with partisans and ideologues.