The Senate’s version of the GOP health care bill, which Majority Leader Mitch McConnell unveiled last week, hasn’t had the smoothest rollout. Some 22 million more people would go uninsured under the Better Care Reconciliation Act by 2026, the CBO announced on Monday, essentially unchanged from the House’s version of the bill. The bill has been criticized both by conservative Republicans, such as Kentucky’s Rand Paul and Utah’s Mike Lee, and by relatively moderate ones, such as Maine’s Susan Collins and Nevada’s Dean Heller. Local newspapers have given it negative coverage. The American Medical Association opposes the bill, as does the AARP, while private insurers have had a mixed reaction. It’s gotten a mainly negative response from conservative intellectuals and policy wonks, although with some exceptions.
All of this has cut against McConnell’s reputation as a strategic genius — to the point where some reporters and commentators have suggested that McConnell intentionally drafted a poor piece of legislation. The New York Times’ Jennifer Steinhauer, for instance, hypothesized that McConnell was hoping for the bill to fail so he could move on to tax reform and other priorities. Balkinization’s David Super argued that McConnell began with a bill he knew “pretty much everyone” would hate so that changes to the bill would make it look better by comparison.
I’d posit a simpler idea: This bill is exactly what McConnell wants because it’s right in line with his long-term goals. As Bloomberg’s Francis Wilkinson points out, the BCRA “will transfer hundreds of millions of dollars from poor and middle-class people, in the form of health care, to rich people in the form of tax cuts.” To be more specific, the bill would cut Medicaid spending by $772 billion over 10 years, according to the CBO, and reduce health care tax credits by about $408 billion. It would also reduce taxes and penalties by more than $700 billion, mostly in the form of “repealing or modifying tax provisions in the ACA that are not directly related to health insurance coverage, including repealing a surtax on net investment income and repealing annual fees imposed on health insurers.”
To put it another way, the BCRA is less a health care bill than a tax cut (that will mostly benefit the wealthy), coupled with a trillion-dollar-plus reduction in federal government spending on health care (that mostly benefited the poor and the sick). Those goals — lowering taxes on the wealthy, trimming the welfare state and reducing the size of government — are at the core of Ronald Reagan’s philosophy of movement conservatism, and they’ve been the primary axis of political conflict between Democrats and Republicans for most of the past several decades.
To Super’s point, the bill does leave McConnell with some room for compromise. There’s more deficit savings than under the House’s bill, so McConnell could cut a deal to get Alaska’s Lisa Murkowski on board — Alaska would be especially harmed by the BCRA because of the cost of health care there — or increase the amount of spending on opioid treatment to help sell Ohio’s Rob Portman and West Virginia’s Shelley Moore Capito on the bill.
But these are matters of tactics, not strategy. McConnell’s strategy is fairly obvious: He wants to pass legislation that lowers taxes on the wealthy and reduces government spending to the largest extent politically practicable.
Republicans probably would have faced some backlash from their base if they’d made no effort at all to repeal and replace Obamacare. But it’s easy to imagine more popular ways to do it. Removing Obamacare’s individual mandate and employer mandates1 could have eliminated some of its least-popular provisions and allowed the GOP to claim victory. McConnell and House Speaker Paul Ryan could have dismantled the Obamacare exchanges but left Medicaid intact. They could have attempted a more comprehensive effort at health care reform, such as the bill proposed by Collins and Louisiana’s Bill Cassidy, which would have given states flexibility in what to do about Obamacare. None of those options would have done as much to lower taxes on the wealthy or reduce government spending, however.
Needless to say, the approach comes with enormous political risk for Republicans. The House’s bill was extraordinarily unpopular: On average, unfavorable views of the bill exceeded favorable ones by 25 to 30 percentage points. (For instance, 59 percent of Americans disapproved of the House bill, compared with the 32 percent who approved, in the most recent CBS News poll.) The Senate’s bill, since it’s substantially similar to the House’s bill, isn’t likely to rate much better.
The unpopularity of the bill isn’t surprising. Government spending on welfare programs has slowly (if not always steadily) increased throughout U.S. history, and while passing these programs is politically challenging, removing them is even harder once you can identify the groups (in the case of the BCRA, everyone from seniors in nursing homes to opioid addicts) who would lose out. Most people are happy with their own health care, so proposed changes to the health care system usually start out facing a headwind.
The bill also comes at an awkward political moment for movement conservatism. The candidates who ran on those ideas, such as Sen. Marco Rubio, flamed out badly in the Republican primaries. Instead, Donald Trump won. But the ideas in the health care bill also aren’t very compatible with Trump’s populism. Trump ran on repealing and replacing Obamacare, but he promised to replace it with “something terrific,” said he’d protect the “lower 25 percent” even if it defied Republican orthodoxy, and repeatedly criticized other Republicans who said they’d cut Medicaid. McConnell and Ryan have co-opted Trump’s mandate — narrow as it was — and tried to turn it into their own, at considerable risk to both themselves and Trump.
Nevertheless, these sorts of opportunities are rare. Republicans hold both branches of Congress and the White House, and these periods don’t always last for very long; Barack Obama and Bill Clinton lost their House majorities after two years in office, never to win them back again, for instance.
So McConnell has come out swinging for the fences. It still isn’t clear whether he’ll succeed. But it also isn’t all that complicated.
CORRECTION (June 27, 11:26 a.m.): A previous version of this article misspelled the names of New York Times reporter Jennifer Steinhauer and the web site Balkinization. The text has been updated.