Healthcare Bill

The current conflict over healthcare bill is a symptom of a much larger ideological clash between two Republican factions.

The Republican Party has become a coalition of old school hard line conservatives” and the populists who no longer feel welcome in the Democratic Party.  These populists are essentially old-school progressives who made up the original working class base of the New Deal Coalition.  They range from the mostly caucasian working/middle class of the American south to struggling rust-belt workers in the midwest.  The southerners in this populist base think of themselves as “conservatives”.  Those of the midwest are more accurately described as “swing voters” who finally swung Republican in this last Presidential race.  None of these populists were very well represented in the Republican Party until Trump came along.  He is their voice.  

The clash over healthcare bill

This friction can definitely be seen in the current divisions over healthcare bill.  The populists object to many aspects of the Affordable Care Act (AKA Obamacare).  Most of them resent the individual mandate and see the ACA as essentially a tax on the middle class to provide subsidized healthcare to the poor.

Those of middle income rarely qualify for subsidies, they must pay a tax of around $600 per year if they don’t have an insurance plan that meets the standards of the ACA, and when they do buy health insurance, the rates have been increasing substantially, as rates increased by an average of 22% this year.  On these points, the Republican coalition is in agreement.

However, the populists don’t object to government involvement in healthcare.  They are very protective of Medicare and to a lesser extent Medicaid.  They are more likely than the “hard line conservatives” to support certain ACA provisions such as the requirement for health insurance companies to cover pre-existing conditions, or allowing the children of health insurance recipients to remain on their parents’ plans until age 26.   They likely support tax credits to help people buy insurance also, though this idea is so new that there are no public opinion polls available just yet.

The “hard line conservatives”, largely represented in the House of Representatives by the House Freedom Caucus (HFC) want a full repeal of Obamacare, subsidies and all, and only support market-based solutions to healthcare reform, such as allowing people to buy across state lines, or allowing people to buy imported drugs from Canada that are often less expensive.  The old school progressives don’t typically object to these HFC provisions.

So the main disagreement is over whether the government should take an active role in healthcare.  They both agree that Obama went about it the wrong way, but the old school progressives don’t necessarily object to the premise of Obamacare.  The disagreement is clearly over Trump’s proposed tax credits, the pre-existing conditions coverage, and the coverage of children on their parents’ plans until age 26.  The HFC is most vocal in their opposition to the tax credits (which admittedly are more of a subsidy), though they hope to repeal these other two parts of Obamacare as well.

Healthcare Bill: This is just getting started

Trump has been meeting with the House Freedom Caucus, hoping to convince them to come on board.  Earlier today he met with some of these salt-of-the-earth populists, truck drivers to be specific, at the South Portico portion of the White House.  

“Obamacare has inflicted great pain on American truckers. Many of you were forced to buy health insurance on the Obamacare exchanges. You experienced a crippling rise in premiums and a dramatic loss in options. And you just take a look at what’s happened to the costs, and it’s incredible…”

It’s people like these truckers, like the factory workers, the construction workers, the skilled tradesmen; these are the voting base of the Republican Party.  Fifty years ago, they were the Democratic base, and Republicans, then made up of a blend of New England moderates (AKA Rockefeller Republicans) and “the real conservatives” were simply accustomed to being the minority party.  This is important to remember because of the blue collar voting base for the GOP, the populists, came over rather begrudgingly to the Republican Party, and most of them have no particular affinity to conservative principles, though most in the south embrace a “conservative” identity.  

The “real conservatives” understand this all too well.  They know that if they allow a partial repeal of Obamacare, one that keeps the subsidies (or just replaces them with something similar), and keeps the other pieces they don’t like, these “real conservatives” know that it will become as entrenched as Medicare.  Minor tweaks will be possible with grueling debate and legislative deal-making, but a full repeal will be impossible.  For the “real conservatives”, this is their last chance.

Trump knows this as well:

“Today, the House is voting to repeal and replace the disaster known as Obamacare. We’ll see what happens. It’s going to be a very close vote. By the way, it’s close not because of Obamacare’s good — it’s close to politics. They know it’s no good. Everybody knows it’s no good. Only, politics. We have a great bill and I think we have a very good chance. But it’s only politics.” 

The politics are, of course, the effort by these “real conservatives” to fully repeal Obamacare.  

Advantage – Populism

Trump seems to be on the winning side of this debate.  The “hard line conservatives” would have preferred a repeal of Obamacare, with a promise to replace it later.  Trump made it very clear at the beginning of his presidency that this was out of the question.  Some kind of Obamacare repeal and replace is almost certain to happen, since the Republicans currently control the White House and both chambers of Congress.

It’s unlikely that the “hard line conservatives” would spoil the opportunity to repeal even part of Obamacare just because they couldn’t get everything they wanted.  They will, however, play this game of chicken with the populists, as they are now.  They hope to get a little more of what they want.

Trump has already conceded on Medicaid, agreeing to roll back the Medicaid expansion under Obamacare.  They hope that Trump will make a few more concessions.  It is doubtful, however.  The “hard line conservatives” may not be happy with Trump, but they need him more than he needs them.  For them, the life and future of the Republican Party depend on Trump’s presidency being at least marginally successful.  They still remember the end of the Bush era.  For Trump, however, a disastrous presidency would simply mean more negative publicity that he could turn to his advantage, a skill in which Trump seems second to none.

For now, the vote on the healthcare bill has been delayed.  The American Freedom Caucus isn’t ready to give in yet on the healthcare bill, and they are using the one power they have.  But much like the Presidential election itself, the “hard line conservatives” are facing two choices: they can win with Trump, or lose without him. This holds true not because of Trump himself, but because of the people he represents.  

Reagan, in 1980, couldn’t have won without these same people, then known as “Reagan Democrats”, or “Hard Hats”.  But while Reagan was a compromiser, a man who bridged the gap between these populists and the “hard line conservatives”, Trump is simply a populist, a self-described “blue-collar billionaire”.  For the first time in the history of the Republican Party, the populists are calling the shots, and the “hard line conservatives” know it. 

Richard Wagner is an Adjunct Professor of Political Science at Florida State College at Jacksonville. He conducts independent study on the American conservative movement and foreign policy. When he is...

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