The election of Donald Trump may have been a game-changer in presidential politics, but on Capitol Hill things really don't look all that different. As the immediate euphoria inspired by the prospect of unified party government has started to wear off, congressional Republicans have gamely returned their attention to a problem that has vexed them for decades and especially for the past seven years: what do they do about health care? Existing confusion is mixed with new urgency, with the repeal and replacement of the Affordable Care Act representing the party's first legislative priority and, according to its own strategic plan, a necessary step before Congress considers tax reform later in the year.
Republican plans to propose a detailed replacement for the ACA have always faced two major problems. The first is that it doesn't appear possible to develop an alternative policy framework that doesn't result in higher government costs, higher consumer costs, a reduction in the quality and quantity of care provided, or a combination thereof. As a party committed, at least in principle, to shrinking the size and scope of the federal government, Republicans understandably don't want to raise public expenditures above where they already are—but the alternative reform options would produce higher premiums and deductibles, less generous subsidies, and/or fewer Americans covered by insurance. None of these potential outcomes will strike the average politician as being particularly popular with the electorate.
The other problem is the existence of serious internal divisions within the congressional GOP. The 2016 election and its aftermath have temporarily eclipsed these conflicts from public view. But a sitting Republican speaker of the House was forced out of office less than 18 months ago by a rump faction of his own party, and there is no reason to believe that the dynamic that led to that extraordinary event has faded away completely.
Indeed, as Congress prepares to debate ACA repeal, we are seeing an all-too-familiar pattern emerging once again. The policy positions of the Republican congressional leadership are simultaneously under attack from two directions: from Democrats, who criticize them as unacceptably conservative, and from the Tea Party right, which characterizes them as not conservative enough. The House Freedom Caucus and like-minded Republicans in the Senate, supported by several key conservative interest groups, are now pushing for a reform bill that is far more "repeal" than "replace," and are threatening to join the Democrats in voting down any health care legislation that fails to meet their ideological demands.
These two problems merged on Thursday into a single bizarre scene in the Capitol building. Annoyed at leaks of previous legislative drafts that produced damaging headlines, Republican House leaders have decided to keep their latest health care reform proposal a secret from everyone except Republican members of the Energy and Commerce Committee. Rumors that the secret plan was being guarded in a basement room in the Capitol prompted congressional critics to engage in a mock-treasure hunt to determine its location and contents. While some Democrats tried to get in on the fun, the chief detective on the case was Republican senator Rand Paul of Kentucky, who even played to the cameras by bringing along a photocopier in order to make a duplicate copy of any legislation he encountered. (The bill's whereabouts, if a draft indeed exists on paper, were not ascertained.)
Paul, a Tea Party ally, has already vowed to oppose any legislation that leaves large sections of the ACA in place, and such a rebellion would need to attract only two other Republicans—such as fellow right-wing purists Ted Cruz of Texas and Mike Lee of Utah—to deny Republican leaders a majority vote for reform in the Senate. As Paul has not only failed to endorse the leadership's repeal efforts but is now openly mocking them to Capitol Hill reporters, prospects for imminent passage of an ACA replacement seem rather remote at this point.
Paul knows full well that his behavior is making the passage of ACA repeal less likely; similar maneuvers by Tea Party types have doomed leadership-backed legislation repeatedly over the past 6 years. But now the White House is in Republican hands as well. For the first time in years, intra-party squabbling and acts of purer-than-thou symbolic position-taking can actually endanger the legislative program of a Republican president.
From what we can tell, there is apparently very little communication between Congress and the White House over policy, so that congressional Republicans have resorted to parsing the president's rhetoric in public speeches in order to divine his views on health care reform. But here is a Republican senator engaged in what looks like a public act of sabotage against one of Trump's biggest stated legislative goals—which immediately raises some curious questions. What, if anything, are the president and his advisors doing, or planning to do, about this ostentatious display of partisan independence? Will they devote any attention and energy to trying to whip Paul, or any other disaffected Republican, into line on ACA repeal? Or do they not actually care enough about the issue to bother?