Today in Bloomberg Opinion: Biden's Had Success with Congress, But He's No LBJ

Some Democrats, justifiably happy with the legislative productivity of the 2021–2022 session of Congress, have gotten a little carried away lately when describing its supposed transformational importance. In today's column for Bloomberg Opinion, I draw on data showing that the last Congress was not historically exceptional in its lawmaking acoomplishments, and suggest that Biden's perceived achievements were made possible by the previous success of Barack Obama in enacting major health care reform in 2010. The piece is also available on the Washington Post site.

Voters Don't Often Reward What They Like...But They Do Punish What They Don't Like

Joe Biden finally signed the infrastructure bill into law this past Monday after a three-month delay separating its approval by the Senate from its passage in the House of Representatives—a delay insisted upon by House liberals who attempted to use it as leverage to guarantee the simultaneous enactment of the larger and more ambitious reconciliation bill. But the reconciliation bill, named the Build Back Better Act after a campaign slogan of Biden's, still remains in legislative limbo, as a few pivotal moderates in the Senate have remained coy about exactly what they will support and when they will support it. The House leadership plans to move forward on the bill as early as this week, but the Senate's timeline for action will remain unclear until the entire Democratic caucus signals that it's ready to proceed. At the moment, final passage of the bill shortly before the Christmas recess seems like the most optimistic plausible scenario for Democrats, and it's still possible that nothing will end up passing at all.

It might seem logical to draw a connection between the slowing momentum of the Biden legislative agenda and the simultaneous fade in the president's job approval ratings over the course of the late summer and fall. Perhaps, one could imagine, voters who are dissatisfied by the pace of national policy change are taking out their frustrations on the president. If this were true, both the recent enactment of the infrastructure bill and the potential forthcoming passage of Build Back Better—both popular measures according to opinion surveys—would hold the promise of giving Biden and his fellow Democrats a popularity boost heading into the midterm elections next year.

One problem with this assumption is that there are other, more convincing explanations for Biden's declining approval. The resurgence of COVID-19 infections caused by the delta variant, combined with the continued disruption of the job market and rising inflation, seems quite sufficient to account for increased public discontent since the spring. Even Biden's imposition of mandates for vaccination or frequent COVID testing as a condition of employment, though favored by a narrow majority of Americans, may have cost him some support among certain segments of the population.

But we also don't have many historical examples of voters rewarding presidents and governing parties for legislative productivity. Even when the bills being passed are popular or transformative, they don't seem to attract new supporters to the president's side or protect him from criticism on other grounds. The congressional sessions of 1965–66, 1981–82, and 2009–10 were all marked by unusually prolific policy-making innovation, enacting laws that continue even today to shape national politics and federal governance. In all three cases, the president's party suffered a significant loss of congressional seats in the subsequent midterm election.

Voters are tough to satisfy and have short memories, especially for success. (In May 1945, Winston Churchill and the other Allied leaders declared victory in the European theater of World War II; two months later, Churchill's party lost 189 seats and control of Parliament to the opposition.) Americans happily accepted the economic stimulus payments included in the American Rescue Plan earlier this year, passed through Congress on a party-line vote, but did not respond to this provision of benefits by showering the ruling Democrats with their enduring affection. But when the party in power does something unpopular, or even fails to effectively ameliorate the day's crisis or economic hardship, we can almost always foresee a public backlash. In politics, grievance is a far more predictable response than gratitude.

Anyone who would wish electoral outcomes to serve as a reliable means of rewarding legislative achievement and punishing legislative inertia will find this pattern endlessly infuriating. But it's a good reason why the importance of new policy shouldn't be judged only through the lens of its potential short-term electoral consequences, which may be nonexistent or even negative. Democrats paid a heavy political cost for passing the Affordable Care Act in 2010, which contributed to their loss of the House for what turned out to be the following 8 years. But when Republicans sought to capitalize on public dissatisfaction with the ACA by attempting to repeal it in the first year of the Trump presidency, the direction of popular sentiment immediately swung in the other direction—and House Democrats soon found themselves back in the majority. A party expecting an electoral reward for enacting new laws may just need a lot of patience; the political payoff, if it comes at all, may not be realized until the opposition comes to power and tries to undo the accomplishments of its predecessors.

The ACA Survives, in One More Victory for Boring Old Liberalism

Plain vanilla American liberalism hasn't been particularly fashionable for a long time, and it certainly isn't now. Anyone who regularly consumes high-status media like NPR or the Wall Street Journal, or who spends any time at all in the Twitterverse, could well conclude that today's politics is mostly defined by a battle between a highly intellectualized, social identity-oriented, self-consciously "anti-establishment" left wing on one side and an array of conservative critics, both Trumpist and anti-Trumpist, on the other.

But when we shift our attention to what the government is actually doing, we see a policy-making apparatus that continues to be dominated by a familiar pragmatic liberal tradition representing the historical legacy of the New Deal and Great Society. The Affordable Care Act is one of this tradition's most important recent achievements, if it's appropriate to refer to a law passed more than a decade ago as "recent." And the Supreme Court's 7–2 decision, announced Thursday, upholding the ACA against what may well be the last in a series of major legal challenges only confirms the resilience of the center-left policy state in the face of dissatisfaction on both ideological sides.

The ACA is complicated. It's inelegant and kludgy. It was designed to patch up the most urgent perceived flaws in the existing health care system rather than to tear it down completely and construct a more efficient and coherent successor. It is easy for its strongest detractors to hate, but hard for even its strongest defenders to love.

And yet the ACA remains a representative model of policy-making because it had two critically valuable qualities: enough initial support to be enacted in the first place and a big enough constituency to protect it from subsequent retrenchment. For all of the well-argued critiques directed its way by dissenters on the left and right, neither side has demonstrated the ability to transform a purer ideological vision into achievable and sustainable policy. Decades of progressive attempts to replace the current health care system with a universal single-payer alternative have yet to bear fruit. Conservatives' philosophical opposition to government involvement in health care provision has historically been a politically potent force when working to block liberal reform proposals before they passed, as in 1994, or when mobilizing an electoral backlash immediately after enactment, as in 2010. But after Republicans gained full policy-making power in 2017, general anti-government sentiment turned out to be insufficiently strong to persuade enough politicians within the party to rescind the ACA's specific benefits once they had actually started flowing to the public.

This same pattern arises in a number of other issue domains besides health care: entitlement policy, education policy, environmental policy. The decades-long conservative project to redefine government's role in society has been largely unsuccessful, except for several rounds of tax cuts (never balanced by corresponding spending reductions) and a few smaller victories on the margins. Donald Trump abandoned previous Republican support for Social Security and Medicare reforms that had always been more effective at attracting damaging Democratic attacks than in producing actual legislative achievements. But Trump was hardly the first Republican leader to depart from shrink-the-government doctrine in search of votes. 

Conservative victories often amount to the successful obstruction of liberal initiatives, or even just a reduction in the rate of government growth, rather than actual rightward shifts in the direction of policy. As popular conservatism becomes more consumed with symbolic and cultural battles, such as the current conflict over the teaching of critical race theory in public schools, the movement's traditional primary objective of rolling back the modern welfare state is either moving down the agenda or increasingly delegated to the conservative judiciary rather than the elected branches of government. (As Thursday's ruling showed, judges may not always be much more eager to take on this assignment than executives or legislators have been.)

In the other ideological direction, an increasingly visible strain of progressive activism has certainly had a measurable effect on perceptions of the American political climate. But so far, its ability to directly impose policy has been mostly restricted to non-governmental institutions controlled by the highly-educated cultural left, such as media companies and liberal arts colleges. The new progressive style has yet to find a secure foothold in elective politics, even in Blue America—where are the socialist state governors? the leftist big-city mayors?—despite plenty of confident assertions that the Bernie Sanders campaigns and the AOC-aligned "Squad" foreshadow the near-term future of the Democratic Party. Conflicts in various left-dominated municipalities over police reform and defunding in the Black Lives Matter era, as well as other similar issues, suggest that there are still many unanswered questions about how this particular ideological framework can and will be converted into specific governing choices.

Traditional pragmatic liberalism is a perennial rhetorical target for people who think of themselves as committed to loftier ideals. On the right, social conservatives like Ross Douthat criticize it for lacking "a clear sense of moral purpose," suggesting that in our time it has become "somewhat exhausted." Purist activists on the left echo these themes, speaking of an age marked by the supposedly catastrophic failures of "neoliberalism" and representing the onset of "late capitalism"—implying that a non-capitalist future is surely soon to arrive.

But old-fashioned half-a-loaf liberalism has proven tough to replace. It's not just that revolutionary change is difficult to achieve in the American political system, though it is. There are also plenty of important constituencies invested in conventional liberal policy-making—classes of credentialed work-within-the-system subject matter experts, institutionalized interest groups that prize partial victories over none at all, and a large number of regular voters who hold moderately left-of-center views on domestic affairs and are wary of socialism and laissez-faire-ism alike. While critics on all sides yawn with impatience for the era of boring old liberalism to end, the boring old liberal ACA has just further entrenched itself, boring old liberals Joe Biden, Nancy Pelosi, and Chuck Schumer are working to enact more boring old technocratic incrementalist liberal policies, and boring old liberalism just keeps muddling through to prevail once again.

Now Trump Wants His Wall, But It Looks Like He's Two Years Too Late

The border wall is often described as Donald Trump's signature issue, his most famous campaign promise, the very rationale for his political career—and therefore the most urgent priority of his presidency. And, indeed, Trump's recent behavior seemingly confirms this view. His unmet demands for $5 billion in wall funding have resulted in a goverment shutdown now approaching three weeks in length, and his first nationally televised Oval Office address Tuesday night, though brief and uneventful, was devoted entirely to justifying this hardball approach to what he characterizes as a "crisis" at the border. Trump is even supposedly considering the extraordinary step of declaring a national emergency that might allow him to move forward on wall construction without congressional approval, though his right to do so would remain unsettled at best for months or even years in the face of certain legal challenges.

Both allies and critics concede the centrality of the wall issue to Trump's political appeal and personal connection with his most enthusiastic supporters. But if building the wall was so necessary to the success of his presidency, why did he wait until now to act?

Trump made a very consequential decision soon after his unexpected election in November 2016 to delegate the prioritization of a legislative program to the Republican leadership in Congress: House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell. And the wall was far from the top priority for either Ryan or McConnell, who cared much more about repealing the Affordable Care Act and enacting tax reform. Addressing those two issues thus became the first order of business for Congress, while objectives that were more personally associated with Trump—like the border wall and infrastructure spending—moved further down the "to do" list.

At least in public, Ryan and McConnell assured Trump and other Republicans that they would get to everything on the agenda. Under the timeline unveiled at a January 2017 party retreat, ACA repeal would be accomplished by March, with tax reform following by the end of July—at which point the first phase of wall funding would be in place and an infrastructure bill would be well in the pipeline. But legislative business has a way of taking longer than expected, and in the end Republicans spent the first nine months of 2017 unsuccessfully attempting to pass a health care bill before giving up and moving to tax reform, which they pushed through in December.

By the time Congress turned its attention to immigration in early 2018, spurred on by the Trump-ordered expiration of the DACA program, a combination of several factors (fast-approaching midterm elections, Ryan's soon-to-be-public departure and its associated internal Republican leadership competition, and an increasingly beleaguered and intransigent White House) limited the potential for legislative accomplishment. Republican leaders successfully convinced Trump to wait until after the midterms to demand his wall money, avoiding an electorally disastrous pre-November shutdown but setting up a standoff in the final weeks of the 115th Congress that has now extended into the second week of the 116th.

One lesson that the Trump White House might have usefully taken from American history is that there is such a thing as a presidential "honeymoon": presidents usually have an easier time working their will in Congress during the early months of their first term than any time thereafter. But Trump, an unsophisticated newcomer to legislative politics with an amateurish and perpetually squabbling cadre of advisors, was not well-positioned to dispute the assurances of Ryan and McConnell that they knew best how to proceed—yet another example of his uniquely weak presidency. Two years later, Trump may come to regret that he didn't insist on funding for the border wall right away; the many months spent fruitlessly pursuing health care reform certainly seem in retrospect like wasted time. Though presidents may gain valuable wisdom through experience in office, the opportunity for realizing ambitious legislative change is greatest when they are still brand new to the job.

Graham-Cassidy Shows That Politics Is About Ideas As Well As Interests

Critics on the left often roll their eyes when conservatives proclaim a principled commitment to the timeless virtues of limited government and cultural traditionalism. To detractors, conservative rhetoric about values is merely a rationalization of, or mere window-dressing for, the right's actual motivation: the defense of existing social inequalities in the domains of economics, race, gender, sexual orientation, and so forth. Conservatives like to portray themselves as committed to a philosophical cause, according to this view, but they really just care about enacting policies that provide their supporters with financial or social advantage at the expense of everybody else.

As Matt Grossmann and I were writing our book arguing that the Republican Party is fundamentally an ideological movement while the Democrats are distinctively a social group coalition, some of our colleagues accused us of taking conservative ideology too seriously as representing something more than a publicly palatable justification of Republican-aligned groups' own collective self-interest. One attendee at the Midwest Political Science Association's annual conference responded to my presentation of some of our early work by complaining that we didn't understand that Republicans simply do whatever their corporate sponsors tell them to do. (She continued to rant about how ridiculous she thought the paper was in the hallway after the panel was over, personally delivering the kind of "spirited feedback" that we academics more commonly experience through the anonymous peer review process.)

It's surely true that citizens' relative degree of receptiveness to the tenets of small-government conservatism is strongly influenced by the extent to which they perceive a personal benefit from the enactment of conservative policies. But a conception of ideology as simply interests-in-disguise can't account for important elements of Republican Party politics, as demonstrated by the party's ongoing attempts to enact health care reform—the latest of which, the Graham-Cassidy bill, appears to narrowly lack sufficient support in the Senate now that John McCain has announced his intention to vote against it.

The Graham-Cassidy plan is opposed by the American Medical Association, by hospitals, and by patient advocacy groups. Despite the common assumption on the left that Republicans reliably carry water for the insurance industry on health care policy (a charge repeated by Jimmy Kimmel during one of his critical late-night monologues this week), major insurers are also strongly opposed. Though the bill was sold as a boon for state-level policymaking "flexibility," several Republican governors and the national association of state Medicaid officers do not support it. In fact, it's very difficult to identify any definable interest group or segment of the electorate whose material interests would benefit from the passage of Graham-Cassidy—even the wealthy, who gained a substantial tax cut under previous iterations of Republican reform, do not receive one here—and it's equally hard to argue that the American public at large is clamoring for its passage.

So why have Republicans made health care reform the centerpiece of their legislative agenda this year, returning to the issue multiple times despite failure after failure? The answer is that most of the key actors within the party are philosophically unreconciled to the use of government power to grant health insurance benefits to large swaths of the population. For some Republican politicians, reducing the public sector's role in the provision of health care has been a personal cause "since [they] were drinking from a keg"; for others, intense pressure from Republican activists and financial donors has spurred them to pursue repeated attempts at reform despite the considerable frustration and political risk involved.

The ideological basis of Republican behavior on health care also accounts for why the party has taken a slapdash approach to the crafting of legislation, pulling together bills affecting a major sector of the American economy in a matter of days without substantial public debate or favorable expert analysis. Most Republican officeholders are not invested in policy details or particularly curious about how their favored reforms would operate in practice. If any initiative that moves public policy to the right is desirable by definition, the specifics are much less important than the general directional thrust.

It's also noteworthy that while Republican health care reform initiatives are most commonly treated as efforts to "repeal and replace" the Affordable Care Act, each major bill—including Graham-Cassidy—has included cuts to Medicaid funding that go well beyond simply rolling back the expansion contained in the ACA. For all the public focus on Trump's supposed personal obsession with exacting revenge on Obama, the true aim of Republican policymakers has consistently been the achievement of a much broader and more permanent reduction of the federal government's health care footprint.

Whether one has been cheering or booing the results, this year so far has marked a clear departure from models of legislative action that emphasize transactional politics among interest-group stakeholders mediated by the application of policy expertise. Of course, such approaches have historically been open to criticism that they are insufficiently informed by broader ideological visions or values. The view that government-provided health insurance amounts to a normatively unacceptable implementation of a leftist or socialist belief system has only become more prevalent among Republicans in recent years, the pragmatic rhetorical patina of Trumpian "populism" notwithstanding. If politics were merely a battle of interests and not a war of ideas, the anti-government health care cause wouldn't keep springing back to life every time it appeared to be DOA.

A Night to Remember in the Senate

The election of 2016 was an unexpected and smashing Republican victory—but it also represented the calling of an awfully big bluff. For seven years, Republicans had pledged to repeal the Affordable Care Act and replace it with a superior, but always unspecified, alternative. Donald Trump famously claimed that he could cover "everybody" at a fraction of the cost of the ACA, but he was hardly the only Republican politician to promise the American people that they could keep everything they liked about Obamacare while painlessly jettisoning the parts they didn't like—the taxes, the mandates, the high premiums.

Once Trump was elected, repeal was no longer merely a symbolic position useful for rallying the Republican base against Obama and the Democrats, but represented a well-established policy commitment to which the party had unavoidably staked itself even though health care reform is predictably treacherous for the party attempting to pass it. Congressional Republicans—first in the House, and then in the Senate—took to developing actual repeal legislation with all the enthusiasm of a teenager who had promised to mow the lawn in exchange for being allowed to go out with his friends the night before, and now had to make good on his end of the bargain.

For in fact there is no magic policy formula that preserves the popular aspects of the ACA while abolishing the unpopular provisions—especially while also remaining true to conservative ideological principles. Many people would have to pay more for their health insurance and many others would lose their coverage entirely. As public opinion polls showed, support for various versions of the Republican health care plan among the electorate was consistently dismal.

What followed over the succeeding few months—right up until the moment that John McCain became the 51st vote in the Senate against repeal early Friday morning—was an attempt by a significant proportion of the Republican conference in both houses of Congress to maneuver so as to avoid blame from the party base if repeal failed while also avoiding responsibility for the consequences of its passage. The result of this mentality was some of the strangest and most confusing legislative behavior that veteran Congress-watchers had ever seen. Bills with wide-ranging policy implications were written in a single afternoon. Individual members made public demands that they then abandoned without explanation days, or sometimes even hours, later. Party leaders kept the process alive by promising that collective agreement around a single set of policies, though never realized, was merely sitting just beyond the next procedural vote.

Even the final Senate bill, the so-called skinny repeal, was sold to Republican senators as merely a vehicle to enter a conference committee with the House that would at long last produce that ever-elusive consensus bill. One Republican called skinny repeal a "fraud" and "disaster" (but voted for it anyway), others warned that while the Senate might pass it the House was strictly forbidden from doing so, and hardly anybody bothered to show up to defend it on the Senate floor—leaving Budget Committee chairman Mike Enzi to filibuster interminably in the face of critical remarks from the Democratic side of the aisle.

As unprecedented—and somewhat ridiculous—as all this was, there was a certain logic to keeping repeal alive, or at least trying to leave its corpse in the lawn on the other side of the Capitol. And nobody wants to be the disloyal teammate. It took a dramatic late-night defection by John McCain, in collaboration with previous dissenters Susan Collins and Lisa Murkowski, to administer the apparent kill shot while onlookers literally gasped in surprise.

Undoubtedly, the three nay-voting Republicans are not the most popular members of their party at the moment—a stunned and furious Mitch McConnell didn't bother to hide his resentment of their actions after the vote on the Senate floor—but they may have merely spared their colleagues more wasted time in the weeks ahead as the party continued to search fruitlessly for consensus. Or, alternatively, agreement might have been achieved, and a bill sent to the president—but then Republicans would have been forced to defend an extremely unpopular piece of legislation in the 2018 and even 2020 elections, confronted with tearful or enraged constituents who had lost insurance and other benefits. McCain, Collins, and Murkowski may never get the recognition from fellow Republicans for doing so, but it's quite possible that they just saved their party's majority.

AHCA, Part II: The Pivotal Votes in the House GOP Are on the Right, Not in the Center

Many veteran politics-watchers have a model in their head that they use to understand both electoral competition and congressional policy-making. In this model, the policy preferences of politicians or voters are arrayed along a single ideological dimension stretching from a left (liberal) to a right (conservative) pole. Faced with a choice between two policies, each individual will reliably prefer the option that is located closest to his or her own ideal position on this spectrum.

Political scientists call this model a "Downsian" conception of politics (referring to its formalization in Anthony Downs's 1957 book An Economic Theory of Democracy) but even non-academics tend to accept its basic premises—which is why ideologically moderate candidates are generally viewed by political pundits as having a stronger chance of election in two-party competition than relatively extreme rivals. One important implication of Downian logic is that the median voters, or median legislators, on this ideological spectrum wield decisive political power, because they are strategically positioned to dictate the ultimate policy outcome. Thus we can end up with moderate policy even when moderates represent a minority of the total population of political actors.

When the Democrats were debating the ACA in 2009 and 2010, they had to pay attention to the demands of the moderate bloc because moderates held the pivotal votes in Congress. There could be 200 Democrats who favored a provision—like the public option—and 30 who opposed it, but the 30 could get their way over the wishes of the 200 because they could always threaten to join Republicans in a majority that would vote down any bill they viewed as too liberal. This is a familiar strategic environment for vote-counting party leaders, and jibes with the intuition of many political analysts.

But the House Republican Party does not really work this way. The members of the House Republican Conference who are the most liable to threaten defection—and to deliver on such threats—are the hard-line conservatives in the House Freedom Caucus. It was the Freedom Caucus that torpedoed Round 1 of the ACA repeal in March, on the grounds that the bill did not go far enough in a conservative direction. And it was the support of the Freedom Caucus this afternoon that allowed the second effort at repeal to narrowly squeak through the House, after winning concessions in the interim that pushed the bill further to the ideological right.

One might expect that satisfying the demands of the Freedom Caucus would doom the bill's support among Republicans representing politically marginal districts. But it turned out that while many of those members communicated great discomfort with its provisions, they were not willing to withstand the political blowback from within their own party by supplying the key votes to kill the bill.

The House GOP is thus in an unusual position in which the pivotal policy influence in the caucus lies on the party's right edge, not in its center. Thus the bill picked up greater support as it moved further in a conservative direction over time—a pattern that is directly inconsistent with traditional legislative logic. Even Republicans from competitive districts became more supportive of the AHCA as it shifted to the ideological right; while they were willing to pile on against the previous version once the Freedom Caucus had already vowed to block it, they were substantially less enthusiastic about courting conservative attacks by opposing the bill from the left once their own votes would prove decisive to the outcome.

It should be noted that the Republican Party's frequent rejection of Downsian logic extends to the electoral sphere as well. Rather than view voting for the AHCA as an unacceptable risk given the law's unpopularity among swing voters, many Republicans believed that they would court greater danger by failing to pass anything and thus demobilizing their own party base:

GOP consultant: "House majority is in greater jeopardy if we DONT pass this than if we do... the bottom falls out if we don't get something"

— Jake Tapper (@jaketapper) May 4, 2017

When a party defines itself as the agent of an ideological cause, it is almost inevitable that many elected officials will perceive political pressure as coming from the extremes, not the center, and act accordingly. Moreover, the lesson that the Freedom Caucus will draw from the events of the past two weeks is that the demands of purist conservative holdouts are likely to be satisfied in the end, while moderates and pragmatic conservatives will cave rather than risk blame for obstructing the policy agenda of party leaders. A national rout in 2018 might call this rationale into question, but for now the typical Republican official views energized conservatives, not moderate swing voters, as occupying the pivotal position dictating his or her own personal electoral future.

Why Wasn't Obamacare Repealed? The Answer Is the Party, Not the President

The American Health Care Act, a.k.a. the House Republicans' plan to repeal and replace Obamacare, thudded to earth on Friday afternoon after Paul Ryan concluded that he lacked the votes to pass it and pulled the bill from the floor of the House. It's always big news when the ruling party fails to enact a major legislative initiative, and even more so just two months into a new presidency. Yet the ensuing media coverage, though extensive, nevertheless gives an incomplete—and perhaps even misleading—picture of how and why the AHCA imploded so quickly and spectacularly.

Most of the stories I've seen—especially on cable news—focus their attention on Donald Trump, portraying the bill's demise as primarily a failure of the president. This is hardly a surprise. Media coverage of American politics often revolves around the presidency while giving much less attention to other relevant institutions and actors, to the extent that citizens tend to overestimate the president's responsibility for outcomes and conditions.

Trump had also set himself up for a splash in the media dunk tank by spending the past year promising voters a health care plan that simultaneously expanded coverage and reduced costs, and by bragging that his unmatched skill at negotiation would easily overcome any remaining policy disagreements. Now that events have confirmed the widespread suspicion that both claims were pure fiction, journalists will not be shy about pinning the AHCA's failure on a president whom they already view as having a big problem telling the truth.

Over the past 24 hours, several inside accounts have been published that portray Trump as having blundered through meetings with congressional Republicans, exposing a lack of policy command and an empty desire to achieve an easy legislative "win" for its own sake rather than a demonstrated commitment to a particular set of substantive goals. Trump and his advisor Steve Bannon also apparently lectured and threatened Republican holdouts in ways that ultimately backfired in attracting support.

Those not inclined to solely blame Trump for the demise of repeal-and-replace—including the White House itself—have mostly aimed their shots at Ryan instead. Liberals who have rolled their eyes for years at Ryan's boy-genius reputation in Washington claim righteous vindication from this week's events, while some conservatives sympathetic to Trump have sought to shift responsibility to the speaker for drafting an unpopular and politically risky bill that could not make it through his own House.

While it's certainly true that both the president and the speaker made mistakes in handling the health care issue, it's inaccurate to portray the demise of the AHCA as primarily a consequence of individual failures of leadership or strategy. Replace Trump and Ryan with Marco Rubio and John Boehner, or Jeb Bush and Kevin McCarthy, and the results would almost certainly be more or less the same. The bill died so quickly, and was so far away from success when it did fail (remember, the House was by all accounts the easier lift of the two chambers), that the specific day-to-day behavior of the principal actors seems inadequate to account for the result.

The real obstacle to the passage of health care reform is the Republican Party itself, and any full reckoning with what just happened has to grapple with that fact. Nearly eight years of attacks on the ACA as a "government takeover" of health care, along with repeated promises to replace the hated Obamacare with an unspecified superior alternative, paid considerable electoral dividends but left the party committed to an unachievable policy goal. Republican leaders desperately sought to placate conservatives calling for a broad rollback of federal responsibilities and expenditures, but they simultaneously refused to acknowledge that satisfying these demands in practice would result in a reduction of coverage and a relaxation of popular regulations—which in turn would alienate swing voters and mobilize political opponents.

The national party has also become increasingly influenced, if not controlled outright, by unelected activists and news media personalities who gained considerable internal power during the Obama years by constantly criticizing Republican officeholders for insufficient ideological loyalty. This dynamic has, perhaps inevitably, resulted in the formation of a faction within the congressional GOP that plays to this constituency, even when doing so is counterproductive to legislative productivity or concrete policy achievement. From the Freedom Caucus in the House to the Ted Cruz-Mike Lee axis in the Senate, the existence of these self-appointed keepers of the purist conservative flame deprives the Republican leadership of a functional partisan majority on major legislation, and this obstacle has not been removed with the election of a Republican president.

Mainstream Republicans, Trump included, have viewed the entire health care policy domain most of all as a useful club with which to beat Democrats, while hard-line conservatives have likewise viewed it as a useful club with which to beat mainstream Republicans. The various partisan and electoral motives at play have often governed Republican behavior to politically successful ends, but few within the party have concentrated on the more difficult and less immediately rewarding task of first developing workable policy alternatives to the ACA and then investing substantial energy in building support for them among their colleagues.

Some critics have argued that the AHCA, a bill that was transparently pulled together in a matter of weeks with little expert input or elite support, ultimately failed because it was bad policy. Maybe so. But we should be wary of the ensuing implication that a "better" bill would have stood a stronger chance of passage in the House. It's fair to criticize Ryan for the legislation that he drafted and promoted, but he presumably believed its provisions would best reconcile the conflicting demands of swing-seat moderates and conservative purists. The revisions made in the final hours in a futile effort to attract greater support on the right suggest that opponents of the bill would not have been easy to satisfy even with a more thorough policy-making process.

Congressional Republicans' increasingly apparent challenges in reaching internal agreement on policy—which even Ryan was forced to publicly acknowledge yesterday—do not bode well for the rest of the party's legislative agenda, from tax reform to appropriations to the looming federal debt ceiling. Nor does the current chaotic state of the Trump administration, which will hardly be in the position to deliver much assistance to Ryan and Mitch McConnell in the exercise of their leadership responsibilities over the coming months.

Up to now, the news media and Washington community have treated Trump's shocking ascension within the GOP as a more-or-less random event—the hostile takeover of an otherwise sound party apparatus. But it's time to devote much more serious consideration to the question of whether its existing internal dysfunction left the contemporary Republican Party uniquely vulnerable to a Trump-led ambush. As any health care expert knows, an effective remedy for one's ills first requires a correct diagnosis.

How the New Health Care Bill Confirms the Asymmetry of the Parties

Matt Grossmann and I write a fair amount about health care in our book Asymmetric Politics because it's a political issue that represents a particularly effective example of our main thesis: that the Democratic Party is organized as a coalition of social groups while the Republican Party is controlled by an ideological movement. Now that the House Republican leadership has released its health care reform proposal—the long-promised plan to "repeal and replace" the Affordable Care Act—it is clearer than ever that the two parties are fundamentally different in character.

The Democratic Party is composed of a number of discrete social groups, each of which pressures party leaders to support and enact policies designed to ameliorate specific perceived problems faced by the group. For decades, Democratic constituencies have demanded that their party act to provide health care benefits to vulnerable populations—a goal that was addressed by the creation of Medicare and Medicaid in the 1960s, the Children's Health Insurance Program in the 1990s, and the Affordable Care Act in 2009–2010.

By and large, Democrats are less concerned about the mechanics by which a policy is implemented than they are about the real-world effects of that policy. For example, the Affordable Care Act did not reflect an overarching ideological vision for the nation's health care sector, but instead was designed to minimize disruption to the existing system (in order to increase its chances of passage through Congress) while extending insurance and other benefits to a greater proportion of the public.

Democratic leaders worked for years to negotiate compromises with a range of powerful stake-holders in order to develop a bill that had a chance of passing into law, in order to achieve at least a degree of policy-making success. Pragmatism, not purity, is the dominant style of governing among Democratic politicians, and even liberals within the party who preferred a single-payer system to the relatively inelegant Obamacare apparatus supported the legislation as a partial victory and the best realistic option available to address the practical concerns of their constituents—rather than torpedoing the entire effort in the name of ideological principle.

The Republicans, as one might observe these days, work differently. The bill that Paul Ryan and his congressional allies have released is not the product of extensive deliberation among interest groups, health care providers, or policy experts. Nor is it designed to achieve a particular outcome with respect to the quantity or quality of coverage available to the public. Instead, the legislation is primarily motivated by the goal of reducing federal involvement in the provision of health care to the extent that is politically possible, repealing the individual mandate (deemed unconstitutionally coercive by contemporary conservative ideology) and imposing significant cuts to the federal Medicaid program.

Much has been made of the fact that the House plans to begin legislative action on the Ryan bill without a score from the Congressional Budget Office estimating its total cost and projected effect on the number of Americans with health insurance. This decision supposedly reflects the desperation felt by Republican leaders to push the bill through the committee process as quickly as possible, as well as an expectation that the CBO's numbers, when they come, will indicate that the bill would cause a sizable rise in the proportion of uninsured citizens.

But the lack of interest in the CBO score also demonstrates what the central purpose of the bill actually is. For Democrats, the point of enacting the ACA was to increase the number of Americans who had health insurance, and any legislation that failed to significantly reduce the ranks of the uninsured was, by that standard, not worth passing. Validation from outside experts that the ACA would indeed fulfill the goal of coverage expansion was thus necessary in order to maintain party support.

Republicans, in contrast, are much more indifferent to the question of what effect their own replacement bill will have on the number of insured Americans. An unfavorable CBO score will be politically damaging, to be sure, but is less likely to influence their evaluation of the inherent merits of the legislation. (Reducing the size of the Medicaid program is fully consistent with the ideological objectives of the party—a feature, not a bug.)

Some liberals have responded to our characterization of the Republican Party as fundamentally ideological by arguing that Republicans don't really adhere to a coherent value system but rather merely do the bidding of wealthy citizens and big corporations. But the Ryan bill can't really be explained on that basis. The rich do benefit by receiving a large tax cut, but if Republicans only cared about that issue they would have chosen to pursue a politically easier path of merely cutting taxes on the wealthy while leaving health care alone. Similarly, it's far from clear that insurance companies are getting much out of the Ryan bill; in fact, the repeal of the individual mandate might well lead to a market "death spiral" that would raise insurance premiums and reduce the number of customers.

But perhaps the strongest current evidence in favor of our argument about the differences between the parties is the unique power of ideologically purist activists and pressure groups within the GOP. In what is surely the biggest political news of the day, one conservative organization after another—the Club for Growth, Heritage Action, FreedomWorks, the Koch-funded Americans for Prosperity—has announced its opposition to the Ryan bill, claiming that it doesn't go far enough in repealing the ACA and reducing the government's role in the provision of health care.

Of course, these groups' criticisms only make it more likely that Ryan's reform bill will fail and the ACA will remain in place, squandering a potential opportunity to move federal health care policy further to the ideological right. As we argue in Asymmetric Politics, it is time to devote more serious attention to the fact that the increasing power of the conservative movement and growing electoral success of the Republican Party over the past few decades have not yet come close to achieving the major retrenchment in domestic policy that the American right has been nominally dedicated to pursuing for most of the last century.

When Republican officeholders repeatedly shrink from risking the popular backlash that would naturally arise from large-scale implementation of their ideological commitments—note how the House GOP has acknowledged that simply repealing the ACA without replacement would invite electoral disaster—the unelected elements of the right respond by attacking them for betraying the Republican Party's conservative principles, threatening their defeat in primary elections and forcing them to make increasingly ambitious future promises that in turn are even more difficult to satisfy in practice. Regardless of where one's own sympathies might lie, observers across the political spectrum should be able to agree that this is not a fertile political environment for the prolific enactment of sound public policy.

Rand Paul Is Busy Blowing Up ACA Repeal. Is the White House Even Trying to Stop Him?

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?

You Gotta Fight For Your Right...to Write the Obamacare Repeal Bill

The Republican congressional leadership's ambition to begin the process of dismantling Obamacare within days of Donald Trump's ascension to the presidency has hit a snag. Mitch McConnell and Paul Ryan had previously agreed upon a legislative strategy of immediately enacting a bill that would ostensibly "repeal" much of the Affordable Care Act (via budget reconciliation legislation, which is not subject to filibuster in the Senate) but would delay its effective date of implementation for at least two years in order to give Republicans in Congress time to develop their long-promised alternative health care reform plan.

Now some fellow Republicans are throwing obstacles in their path. Five members of the Senate majority have introduced an amendment that would effectively delay a vote on repeal until March, while a few others have suggested that the ACA should not be repealed until a replacement plan is ready to be enacted in its place. On the House side, members of the arch-conservative Freedom Caucus have also threatened to oppose the Republican leadership's budget resolution when it comes up for a vote later this week unless they receive more specific information about the nature and timetable of ACA repeal-and-replace legislation. (Passage of the budget resolution through both chambers is a necessary first step to use the filibuster-proof reconciliation process to repeal provisions of the ACA.)

We might expect politicians to get a case of political cold feet about the risk of voting to upend the entire health care industry in potentially unpredictable ways, as well as the potential fallout of revoking public benefits from millions of citizens. Otherwise staunch ideological conservatives like Tom Cotton of Arkansas and Rand Paul of Kentucky have objected to the leadership's fast-track approach; it's hardly a coincidence that both senators represent states that have experienced a significant decline in their populations of uninsured residents under the ACA. Republican senator Shelley Moore Capito of West Virginia, another state with many ACA beneficiaries, even endorsed the idea that any replacement health care plan should cover more citizens than Obamacare does—a telling concession to the complex political considerations that Republicans now face as they try to square their small-government philosophical predispositions with their electoral survival instincts.

But that can't be the whole story. After all, the House Freedom Caucus is famous for claiming unmatched devotion to conservative principle and for constantly criticizing the Republican leadership from the ideological right. It's hard to envision its members going wobbly on ACA repeal before Trump's term has even begun—especially since they uniformly represent deep red districts with little chance of serious challenge from the Democratic opposition.

What's also going on here is the preliminary round of what may prove to be a significant internal battle within the Republican Party over the legislative specifics of repeal-and-replace. The absence of a party-endorsed replacement plan for Obamacare over the seven years and counting since one was promised by the congressional GOP reflected the difficulties that party leaders faced in uniting Republican members around a single alternative—but this policy void must be filled now that repeal-and-replace has evolved from catchy slogan to legislative agenda. Various key actors within the party will now seek to maximize their leverage over the policy-making process, which often involves threatening or even imposing procedural obstacles to the passage of reform unless and until they gain the opportunity to exert influence over its shape. The Freedom Caucus is not averse to making common cause with Democrats to outvote its own party leadership on the floor of the House, while the small group of Republican senators currently making trouble for McConnell similarly constitute a strategically pivotal voting bloc, given the close margin of party control in the chamber.

Jonathan Chait and Brian Beutler argue that the public maneuvering of the past few days indicates that there probably aren't 51 votes in the Senate to repeal and replace the ACA in anything other than cosmetic fashion. That's true for the moment, though it would be premature to conclude that repeal is doomed to failure. At this stage, it's likely that the senators currently wandering off the leadership reservation are raising public doubts in order to assert control over the reform process rather than to derail it entirely. Tellingly, one of the troublemakers is Lamar Alexander of Tennessee, chair of the Senate Health, Education, Labor and Pensions Committee, who might well be expected to seize an opportunity to establish his own independent authority over both the substantive and procedural content of reform. The relatively pragmatic and policy-minded Alexander will be in the position to argue that the only bill with a prayer of passing the Senate will be one that he writes himself, and that his committee—not the House leadership or the hard-line Tea Party bloc—should therefore take the lead in developing the elusive Republican alternative reform package.

Such claims will not sit well with the Freedom Caucus or other Republican factions, which will use similar tactics in order to seek control of the process for themselves. This fight could get messy, and the current GOP congressional leadership does not have an impressive record of successfully uniting its members in support of ambitious, complex, politically controversial policy initiatives. It's not difficult to imagine large-scale reform ultimately foundering due to unresolvable differences between the House and Senate, or between party pragmatists and conservative purists. Over the past few weeks, as the reality of imminent one-party rule has begun to settle upon Washington, a number of Republican officeholders have begun to acknowledge that "repeal-and-replace" is much more complicated in practice than it might have initially appeared.

However, it's very difficult to gauge the prospects for ACA repeal without further insight into the intentions of the new president. Donald Trump holds unique political influence within his party that he could exploit to crack some heads on Capitol Hill and get a deal done (what Republican member of Congress would want to end up on the wrong side of a presidential Twitter rant?). If Trump identifies ACA replacement as a top priority and devotes the necessary attention and energy to the issue during the first months of his presidency, it would be hard to deny the possibility of legislative success—even if it were followed by significant policy complications that would then invite a popular backlash against Republican politicians.

If he really wants fundamental reform to pass, however, Trump will have to assure congressional Republicans that he won't sell them out. There will be some unavoidable political costs to a true repeal-and-replace approach, and GOP members will need Trump to provide them with political cover by sharing these costs. Right now, they are probably unsure of his loyalty—and, based on his past behavior, they have reason to be. 

What happens when citizens, some of them Trump supporters, begin to complain that he and his party are messing around with their health insurance? Does Trump take responsibility for the policy implications of repeal-and-replace, or does he respond to blowback by disavowing the Republican replacement plan and blaming Congress for any unpopular consequences? It would truly be a political nightmare for congressional Republicans if they were to cast tough votes to repeal the ACA only to have a president of their own party join the chorus of critics.

So far, it doesn't seem as if the incoming president has communicated to congressional Republicans that health care reform is in fact his primary legislative objective, or that he will stand with them politically over the months and even years that will be necessary to see it through to completion. One senator even pleaded with Trump this week to clarify his health care ideas via Twitter—which, though it inspired some mockery, would at least have the advantage of publicly committing the new administration to some specific choices and thus send valuable signals to the Hill about how best to proceed.

ACA repeal isn't dead, but it faces little chance of surviving the arduous legislative process without significant presidential investment. Unless Trump is willing to publicly and privately devote himself to the cause (and assume the corresponding political risks), Congress is unlikely to do the heavy legislative lifting required to enact significant further change to the American health care system. If he wants to claim victory over Obamacare, Trump needs to join the fight.

How Obamacare Repeal Illustrates Conservatism's Central Challenge

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.