Over the past eight years, the Republican Party has publicly stood for nothing so much as the proposition that the Affordable Care Act—a.k.a. "Obamacare"—is more than just a misguided set of public policies but is in fact a fundamental threat to cherished values. Congressional Republicans have referred to the ACA as a "stunning assault on liberty" that "tramples on the freedoms of Americans" and is itself "un-American"; former party leader John Boehner warned in 2010 that the legislation would cause an "Armageddon" that would "ruin our country." The implementation of the ACA's provisions over the course of Obama's presidency has done nothing to reconcile the GOP to the act's existence nearly seven years after its enactment, and party members have energetically pursued various attempts to overturn or undermine the law—from judicial challenges to state-level Medicaid expansion blockades to the unsuccessful Ted Cruz-led government shutdown maneuver in October 2013.
Soon after the ACA was passed, Republicans collectively adopted a slogan of "repeal and replace"—committing the party to repealing the hated Obamacare while replacing it with a "better" alternative. Republican politicians have not found much success in specifying exactly what that alternative would be, despite repeated promises over the past seven years that the public unveiling of their own detailed health care plan was just around the corner. Even if the GOP's pledge to enact a different version of health care reform represented a clever rhetorical strategy more than a serious policy position, however, it still contained a key implicit concession. By promoting the idea of a superior legislative replacement (however hypothetical it might be), Republican leaders were acknowledging that the central purpose of the law itself—government-initiated expansion of citizen health-care access—was not per se illegitimate, and that revoking the benefits provided by the ACA to millions of Americans by merely ripping out Obama's reforms by the roots was not a politically palatable stance.
With Donald Trump about to assume the presidency, Republican leaders are now considering how best to translate the "repeal and replace" pledge into a concrete legislative program. This has proven difficult. Congressional Republicans understandably wish to satisfy their own ideological commitments (and the demands of their party base) by moving quickly to pass repeal legislation. But without a replacement proposal ready to go, the current strategic plan involves delaying the actual implementation of repeal for two years or more.
In some respects, advocating such a relaxed timetable is a curious position for a party that has previously characterized the ACA as representing a menacing threat to the very future of America itself. But Republicans have found themselves in a genuine political bind. Repealing Obamacare carries substantial political risks for the GOP; voters seldom reward politicians for denying them benefits that they have previously enjoyed, while the health care industry as a whole could experience substantial disruption due to funding cuts and uncertainty about future federal policy. (Even the kick-the-can-into-2019 approach currently favored by Republican congressional leaders could have the effect of unraveling the individual insurance market as early as this spring, if insurers respond by pulling out of the marketplace ahead of schedule.) With unified Republican control of the federal government arriving on January 20, voters would not be confused about which party to blame for any problems that might occur.
The Republican health care dilemma has become a microcosm of the larger challenge faced by the conservative movement for the better part of a century. American conservatives are committed to the ideal of limited government power as a means of protecting individual liberty, and have repeatedly promised to achieve "revolutionary" reductions in the size and role of the federal state. Yet rolling back the scope of government is very difficult in practice, since most of what it actually does—providing benefits to various classes of citizens—is politically popular. Even conservative politicians maintain an instinct for electoral self-preservation that encourages them to assure constituents that nobody will be left worse off by their policy proposals, and some conservatives have been known to support new expansions of federal responsibility, despite their stated small-government principles, as an effective means of appealing to voters.
Thus the increasing electoral success of an increasingly conservative Republican Party over the past 40 years of American politics has yet failed to result in an overall reduction of federal authority. When conservative activists complain that Republican politicians talk a good game about shrinking government but seldom follow through once in office, they have something of a point. As Matt Grossmann and I explain in Asymmetric Politics, much of the GOP's distinctive governing behavior reflects the enduring gap between the American public's general preference for "small government" in the abstract and its collective support for most specific government activities.
Republicans are therefore simultaneously filled with excitement about the prospect of repealing Obamacare—or, at least, passing legislation that can be sold to the party base as repealing Obamacare—and rife with anxiety about being blamed for any unpopular consequences that might ensue. One interested party has recently communicated some concern on this point. In a series of tweets posted on Wednesday, Donald Trump exhorted Republicans to "be careful" to make sure that "Dems own the failed Obamacare disaster" which, he predicted, would "fall of its own weight."
Trump's words reflect a recognition that the "big-government" ACA has served as a highly effective foil for Republicans during the Obama presidency, but that the partisan calculation is likely to change once the GOP assumes sole responsibility for federal policy-making. Politically speaking, it's much easier to continue to rail against the Democrats from the opposition bench than to start fiddling around with people's health insurance in a way that might put one's own party on the defensive. Of course, if Republicans do receive blame for any changes to the American health care system that inspire a popular backlash over the next four years, such blame will be shared by, and even primarily directed at, the next occupant of the White House—even if his substantive role is limited to signing legislation crafted by his fellow partisans on Capitol Hill. The recent Twitter record suggests that such a realization is dawning on said occupant.
It is still very difficult to predict exactly what health care policies will be enacted by the incoming Congress and presidential administration. Most probably, Republicans will successfully rescind some of the ACA's provisions while leaving others at least partially intact. For Democrats who view the legislation as one of their party's most important and hard-won policy achievements, even an incomplete dismantling of the law will be a heavy blow. Yet anything less than total repeal-without-replacement will result in a federal role in the health care realm that will remain larger in 2020 than it was in 2010—rendering the conservative movement's central goal of reducing the government's reach in domestic affairs that much further away from realization.