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.

Democratic Debate Analysis (First Night): CNN Decides What the Race Is About

Honest Graft was on vacation during the first pair of Democratic presidential debates last month, so this week's events are the first of the 2020 campaign that will receive recaps here on the blog. Perhaps it's worthwhile, then, to review my general perspective on debates before proceeding to discuss Tuesday night's proceedings.

• I tend to be skeptical of analysts' confident declarations of debate "winners" and "losers," because the standards by which such pronouncements are made are usually unclear and are often colored by previous preferences. However, a strong collective judgment among media figures about who did well or who committed a major gaffe can affect candidates' fortunes in important ways, regardless of the fairness of such evaluations.

• Debates can tell us important things beyond who won or lost. They help illustrate candidate strategy, internal party trends and developments, and media preoccupations. But most debates don't turn out to be dramatic "game-changers" in the race as a whole.

• As tools for voters to learn about candidates and make decisions about whom to support, debates are not entirely useless—but neither are they reliably helpful. Rather than adopting the common media theme that debates are sacred exercises in civic enlightenment, citizens should treat them more like the television productions that they are at heart. Television can be entertaining, but it's not reliably informative.

Now, on to a few takeaways from the first night's debate:

1. There was a chance that the random assignment of Sanders and Warren to the same debate stage this month would lead to a showdown between them, but that didn't happen. Instead, the most common dynamic was one in which both candidates were lumped in together as targets of criticism from more moderate rivals.

2. This dynamic didn't just naturally happen on its own; it was largely the consequence of CNN's choice of questions. The moderators, who displayed a curiously hostile tone throughout the evening, were clearly most interested in defining the race as a battle between ideological purity and electoral formidability—a frame to which they frequently returned. (CNN's post-debate coverage summarized the event by repeatedly displaying the chyron "Breaking News: Liberal and Moderate Democrats Clash in Detroit.") The moderators' behavior had the inevitable effect of minimizing the differences between Sanders and Warren, while making the two of them stand out dramatically from the rest of the field.

3. John Delaney, Steve Bullock, Tim Ryan, and John Hickenlooper all repeatedly accepted the moderators' invitations to make attacks against Warren and Sanders, but the short response times imposed by CNN (as low as 15 seconds in some cases) meant that these candidates didn't have as much of a chance to explain what made them, personally, the best alternative to the two leading lefties in the race. There's a long historical tradition of Democratic candidates distancing themselves from the left edge of their party—and convincing the Democratic electorate that they are smartly positioning themselves for the general election by doing so. But previous Democrats who have successfully employed this approach en route to the nomination have had some other quality that could excite the party's voters: impressive biography, youthful charisma, policy wonkery. Without an immediately obvious personal selling point, these candidates need to make a positive case for themselves as well, but the format was not well-suited to this objective.

4. Amy Klobuchar, interestingly, didn't really take the opportunity to join in the push against the left, despite her self-positioning as an electable midwesterner. (She preferred the popular moderate tactic of attacking the other party instead.) Klobuchar seems to be doing just well enough in polls and donations to qualify for the next debate in September, so she's not in imminent danger of being culled from the race, but as the resident of a neighboring state she'll need to make a big splash in Iowa or she'll be written off before the New Hampshire primary.

5. After (mostly) uniting around the ACA, the presidential wing of the Democratic Party is splintering again on the issue of health care, with substantive policy differences among candidates sometimes illustrated, and sometimes confusingly obscured, by the invocation of phrases like "Medicare for All." Whether or not Democratic primary voters consciously base their choice of candidate on the issue, the 2020 nomination contest will determine whether the party enters the general election on a platform of advocating the wholesale restructuring of the American health insurance system. A vote for Sanders or Warren as nominee is partially a bet that such a position is now viable in a national race.

Ten Years Later, the Democrats Are Still the Party of Obama

In the wake of a "wave" election, it's always more fashionable to emphasize change over continuity. Despite plenty of talk these days about electoral realignments, resurgent socialism, and the political coming-of-age of a potentially transformational millennial generation, however, neither of the two parties looks all that much different now than it did before November 6—even if the national balance of power between them has shifted. To the extent that the 2018 campaign brought internal change to either side, it has mainly served to reinforce the existing nature of each party—and to render the parties even more dissimilar from each other.

A few years ago, in the aftermath of Bernie Sanders's presidential candidacy, I expressed skepticism that the Sanders brand of politics represented a likely future path for the Democratic Party. While Sanders himself mounted a more successful challenge to Hillary Clinton than many analysts had initially expected, his disinclination to emphasize policy issues outside his core agenda of economic redistribution—and, relatedly, his difficulty in making greater inroads within several key party constituencies—ultimately limited his appeal. Sanders was also ill-positioned to consolidate influence within the structure of the Democratic organizational network after the 2016 nomination race in order to reorient the party toward his own priorities over the long term. Barack Obama had become the face of the Democratic Party during the preceding eight years, and I suggested that future Democrats would likely continue to follow his political approach even as Obama himself prepared to leave public office.

Now, a full decade after Obama's first election and nearly two years after his presidency ended, Obama-style politics remains alive and well. Indeed, the Democratic Party continues to be molded in Obama's image even though he no longer serves as its official leader. The candidates who led the Democratic electoral resurgence in 2018 collectively represent a new cohort of mini-Obamas, reflecting the enduring influence of his strategy and style in a number of specific respects:


1. The personification of "change." Obama's decision in late 2006 to seek the presidency after less than two years in the Senate was viewed by contemporary observers as a very bold, if not risky, move. Conventional wisdom suggested that voters might deem Obama unprepared for the job, or scoff at his lack of legislative accomplishments. Instead, Obama turned his inexperience into a political strength in his races against both Hillary Clinton (in the Democratic primaries) and John McCain (in the general election), separating himself from an unpopular class of veteran politicians while promising to offer a different, more hopeful future. His personal biography—relative youth, recent arrival on the national scene, absence from the partisan wars of the previous years—thus reinforced his central campaign message in an unusually effective manner.

Many of the successful Democratic candidates in 2018 also credibly, and potently, positioned themselves as political outsiders opposing "career politicians" or "a broken Washington." Nearly two-thirds (64 percent) of the newly-elected Democrats in the House of Representatives lack previous experience in elective office—including 80 percent of those who captured seats previously held by Republican members. Like Obama in 2008, this Democratic freshman class is also unusually young, with 14 members under the age of 40 and a median age of just 45.


2. Acting liberal, but not talking liberal. Unlike Bill Clinton, Obama did not openly distance himself from, or pick fights with, the left wing of his party, and he generally took firmly liberal positions on major policy issues. At the same time, however, he consistently declined to portray himself as guided by a comprehensive ideological value system. While Democrats in safe party seats have become more likely over the past few years to identify themselves as "liberals" or "progressives" and to push for ambitious left-wing initiatives like single-payer health insurance, Democrats in competitive races mostly followed the Obama playbook in 2018 by running on specific proposals that would represent incremental left-of-center shifts—or even by defending the policy status quo against Republican-imposed rightward changes—instead of offering a more transformational vision.


3. A party of the metropolitan North, not the rural South. Though it had been in motion for a full half-century, the pro-Republican realignment of the South further accelerated during the Obama presidency. The mobilization of anti-Obama backlash in the 2010 and 2014 midterm elections wiped out most of the remaining moderate Democratic officeholders in the South (as well as the rural Midwest and West). Despite an otherwise favorable electoral climate, Democrats mostly failed to make up this lost ground in 2018, and even suffered further defeats in the Indiana, Missouri, and North Dakota Senate races, plus two House seats in outstate Minnesota. The most promising geographic terrain for the post-Obama party to make countervailing gains is now clearly located in the suburbs of major metropolitan areas, home to many highly-educated voters who have been drifting away from the GOP since the 1990s but who are especially alienated by Trumpism.


4. Demographic diversity. It's important to remember how rare it was in the pre-Obama era for non-white politicians to be elected, or even to run competitively, in majority-white constituencies. Obama himself was only the fourth African-American since the end of Reconstruction to win a statewide election for senator or governor  when he was elected to the Senate from Illinois in 2004, and there was considerable skepticism in many corners that a minority candidate could win the presidency up until the very day of the 2008 election. But the number and geographic reach of non-white nominees has continued to rise in subsequent years, and the 2018 contests produced an abrupt spike in the number of successful minority candidates. Democrats of color newly elected to the House from majority- or plurality-white districts include Ayanna Pressley of Massachusetts, Jahana Hayes of Connecticut, Antonio Delgado of New York, Andy Kim of New Jersey, Lauren Underwood of Illinois, Ilhan Omar of Minnesota, Sharice Davids of Kansas, Lucy McBath of Georgia, Colin Allred of Texas, Xochitl Torres Small of New Mexico, and Joe Neguse of Colorado, while Andrew Gillum of Florida and Stacey Abrams of Georgia ran near-miss campaigns for governor.

It seems quite apparent that working to increase the demographic diversity of elected representatives has become a priority for many Democratic activists and voters across racial, religious, and gender lines in the post-Obama era. This year also produced a record number of female candidates for office on the Democratic side, representing a sharp popular backlash to Trump's victory over Hillary Clinton in 2016. In the next session of Congress, white men will constitute less than 40 percent of the Democratic caucus in the House for the first time in history—but will remain about 90 percent of the Republican conference.


5. Health care, health care, health care. More than eight years after it was enacted, Obama's signature legislative achievement is still a highly salient issue in American politics. But while Democrats found themselves on the political defensive over the Affordable Care Act in the years after its passage, the unpopular Republican attempts to roll back the ACA's provisions once Trump took office fundamentally reshaped the partisan dynamics. The Wesleyan Media Project found that while Republican candidates were much more likely than Democrats to mention health care in their advertising in every election between 2010 and 2016, in 2018 it was Democrats who couldn't stop talking about the issue—invoking it in more than 50 percent of all television spots. Even with Obama long departed from the White House, Obamacare remains an extremely hot electoral topic.


There are other ways in which Obama's legacy continues to shape the Democratic Party—for example, a number of newly-elected congressional Democrats are Obama administration or campaign alumni, including Kim, Underwood, Tom Malinowski of New Jersey, Haley Stevens and Elissa Slotkin of Michigan, and Deb Haaland of New Mexico. In general, the changes evident on the Democratic side in the Trump era have brought the party even more in line with the politics of its most recent president than it was when he first ascended to the White House. But as the 2020 campaign begins to stir, the durability of Obama's brand of Democratic politics will soon face yet another historical test. Will Democratic voters choose another Obama-esque figure? Or, perhaps, will they signal their support for their ex-president by nominating his own former second-in-command?

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.

The Demise of the Health Care Bill Shows That Policy Still Matters

Over the past few years, it's become fashionable among many political experts to deny that policy substance plays much of a role in motivating the electoral choices of the American public. The dominant picture of citizen behavior in contemporary accounts is that of a crude tribalism, in which individuals' salient social or cultural identities motivate them to develop a simplistic but powerful affinity for a favored party—and an even stronger antipathy for the opposition—that subsequently determines their normative, and even factual, political beliefs. A number of my fellow political scientists are fond of quipping on Twitter that "all politics are identity politics" and that "negative partisanship rules everything" whenever evidence arises of such phenomena at work.

Like any pithy aphorism, these observations contain substantial, but not total, truth. Today's electorate is indeed strongly partisan in its candidate preferences, and much of this party loyalty is driven by an increasingly bitter feeling toward the other side (rather than a more positive view of one's own party). Many Americans do perceive political conflict as involving competition among social groups, and their own group identity often plays a powerful role in determining which partisan team they join and which they scorn.

But a theory of voting behavior that stops there cannot account for every important development in politics today, and the apparent demise of Mitch McConnell's health care bill in the Senate late Monday is one key example. There will no doubt be numerous inside-baseball reports and analyses about how and why the legislation has failed (at least so far) to attract the necessary support. But it's also worth stepping back and looking at the big picture. The largest single obstacle that the Republican Party has faced in repealing the Affordable Care Act has been the policy preferences of the American people.

While the ACA itself proved to be a divisive measure, most of its specific provisions have consistently enjoyed strong popular support. Moreover, repeal faced the same problem any other attempt at welfare state retrenchment creates: how does a political party revoke benefits from sympathetic current beneficiaries without provoking a serious popular backlash? Prior to Trump's election, Republicans—including Trump himself—could sidestep these dilemmas by keeping their alternative health care proposals vague and implausibly attractive. Once the GOP was compelled to write an actual bill, however, it unenthusiastically produced a set of policies that were almost historic in their unpopularity. Even Republican voters reported lukewarm-at-best attitudes towards the positions of their own party leaders—demonstrating that tribal loyalty still has its limits despite our unusually polarized climate.

If Republican members of Congress thought that mere group solidarity ruled the electorate, they would have resurrected the repeal bill that passed the House and Senate in 2015 (only to be vetoed, as expected, by Obama), quickly enacted it on a party-line vote last January, and moved on to other business—secure in the belief that any supporters who subsequently lost health insurance access could be easily convinced that their favored party was not to blame. Instead, the GOP embarked on a protracted, and so far unfulfilled, struggle to reconcile its ideological predispositions with the substantive demands and anticipated responses of the broader electorate. Donald Trump's bully pulpit and Mitch McConnell's tactical acumen have not yet proven able to overcome the suspicion among a critical mass of officeholders that politicians who defy the will of the public on important national policy issues risk popular retribution at the next round of balloting, regardless of the party label next to their name.

November 2018 Is Still a Long Way Away

The results of the special House election in Montana last week—where the Republican candidate won by a single-digit margin in a "deep red" constituency—are best interpreted as providing one more data point in favor of the conclusion that the national political environment has undergone a substantial, though not necessarily fatal, shift away from the Republicans and towards the Democrats since the inauguration of Donald Trump. This swing is thoroughly consistent with the larger back-and-forth pattern of partisan competition for the past 25 years, in which achieving unified control of Congress and the presidency has consistently rendered a party vulnerable to immediate popular backlash.

On the basis of history alone, then, there is good reason to expect the 2018 election to produce a more favorable outcome for the Democrats than 2016. How much more favorable, however, is impossible to foresee so far in advance of the vote. Eighteen months is a long time in politics under normal conditions—conventional wisdom would have bet overwhelmingly at this stage against the final results of the 1992, 1994, 1996, 1998, 2006, 2010, and 2016 elections. And we are not currently in normal conditions; if anything, the speed of political developments is unusually quick these days, and the level of uncertainty about future events is even higher than usual.

From today's perspective, there are at least two major political issues that are likely to exert a significant effect on the results of the 2018 midterms. One is the Trump-Russia connection and its associated complications, stretching from Wikileaks to Michael Flynn to Jared Kushner to the FBI. Though the appointment of a special prosecutor suggests that this story isn't fading anytime soon, it's impossible to predict what directions it will go over the next year and a half, and what response it will produce in the mass electorate. The key question lurking behind the Russia affair—the extent of Trump's personal knowledge of, or involvement in, any illegal or shady activity—is not much clearer now than it was at the beginning of his presidency, and there is no guarantee that the Mueller investigation will provide a clear answer before November 2018.

The second significant and unpredictable factor in 2018 will be health care: specifically, whether the Republican-controlled Congress will succeed in enacting health care reform, and—if so—what form such legislation will take. The House narrowly passed a reform bill in early May, but Senate Republicans have opted to write their own version from scratch—an effort that already seems to have encountered serious problems. Whether the Senate will be able to pass a health care bill of its own is itself difficult to determine (Republicans can only afford two defections out of a 52-member conference). And whether any bill crafted to survive the Senate gauntlet could then serve as the basis for successful reconciliation negotiations between the two chambers is itself very difficult to know in advance, at least until its major provisions come into greater focus. Whatever the Republicans wind up doing about health care, from passing nothing at all to pushing through a substantial rollback of the Affordable Care Act, is almost certain to carry an electoral cost in 2018, but how big a problem health care will be for the party is impossible to ascertain before it's apparent what the policy change (if any) will be and when it will take effect.

So even excluding the unforeseeable events—foreign crises, terrorist attacks, economic trends—that may well occur and further influence the electoral balance between the parties, we have little reason to believe that the political climate will remain stable between now and November 2018. It's more likely that things get better for the Democrats than for the Republicans, given the performance of the Trump administration and the 2017–2018 Congress so far, but the range of plausible outcomes is exceptionally wide. Due to a structural Republican advantage in the ways that House districts are drawn and in the specific Senate seats up for election in 2018, even a decided nationwide pro-Democratic trend may not prove sufficiently strong to hand the party control of either chamber.

The special election approaching on June 20th in what has become a nationally representative suburban Atlanta House district will almost certainly be treated as an electoral bellwether by the news media. But even if the results accurately reflect the political environment of the moment, we're still so far away from the midterms that there is little sense in interpreting the Georgia race as an indicator of which party is favored to win the most seats in 2018. Throwing up your hands and saying "it's just soon to tell" is not a good strategy for advancing one's career in public punditry, where the constant reading of tea leaves is part of the job description. But in this case, it is just too soon to tell—so beware of anyone who says differently.

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.

What's a President Gotta Do to Be Called a Conservative These Days?

Donald Trump's conservative credentials have been disputed by all sides from the moment that he emerged as a leading contender for the Republican presidential nomination in the summer of 2015. The editors of the National Review denounced him as a "philosophically unmoored political opportunist" in a special anti-Trump issue early last year, while both Hillary Clinton and Barack Obama characterized Trump as unfaithful to conservative principles during the 2016 general election. Trump's success in capturing the Republican nomination and then the White House prompted some observant analysts on both the left and the right to conclude that the Republican Party is no longer the party of conservatism and that a realignment of the entire American party system is now underway.

We are now two months past the presidential inauguration—and while there have been a number of surprises and unprecedented acts both large and small, the actual policies and personnel of the Trump administration have emerged with some clarity. What they add up to, at least so far, is as conservative a presidency as any in modern history. Trump has endorsed an orthodox conservative legislative agenda on taxes, regulation, and health care (including a major cut to Medicaid)—and has even apparently pressured Paul Ryan to revise the House health care bill in order to address objections from hard-line conservatives. His budget proposal calls for shifting billions of dollars from domestic discretionary programs to national defense, prompting opposition even from some conservative members of Congress. On foreign policy and immigration, Trump only differs from other Republicans to the extent that he has staked out positions further to their ideological right.

Trump's hiring and appointment record tells a similar story. His cabinet is filled with conservative stalwarts like Jeff Sessions, Tom Price, Ben Carson, and Betsy DeVos. Prior to his selection as Trump's budget director, Mick Mulvaney helped to depose John Boehner as Speaker of the House because he viewed Boehner as insufficiently devoted to conservatism. Neil Gorsuch, Trump's nominee for the Supreme Court, is a Federalist Society-style conservative jurist. Top Trump aides Steve Bannon and Stephen Miller are likewise firmly on the right end of the ideological spectrum, and palace-intrigue accounts of the Trump White House indicate that Bannon, Miller, and their allies nearly always prevail in internal disputes.

One reason for the strong right-wing character of the Trump administration is that a party, and even a presidency, is much bigger than one person. The Republican Party is increasingly controlled by ideologically-oriented politicians, activists, and media outlets, and Trump needs to work with, and maintain support from, his fellow partisans in order to govern. During the 2016 campaign, Trump sometimes promised to address policy goals that didn't fit within conservative doctrine—increasing public infrastructure spending, renegotiating trade deals, providing childcare assistance, lowering prescription drug costs—but few other Republicans, in Congress or elsewhere, share these priorities. Declining either to pressure his fellow partisans to modify their views or to build a bipartisan coalition with Democrats, Trump has yet to emphasize any of these issues since taking office.

Another explanation lies with Trump himself. There is little reason to believe that Trump is unshakably devoted to the tenets of conservative political philosophy as a personal value system. But Trump demonstrates two other characteristics that attract him to the pursuit of ambitious conservative policies: (1) a desire to project strength, decisiveness, and success by achieving large-scale—one might say "big-league"—political change; and (2) an eight-year-long resentful preoccupation with Barack Obama that has continued without abatement into the new administration, perhaps suggesting to the current president that any dramatic reversal of a policy supported by his predecessor is by definition a worthy and politically advisable act.

The gap between Trump's own public statements and his administration's actual issue positions is sufficiently large that some people are starting to wonder if Trump even understands the content of the legislation that he has endorsed and is pushing through Congress. Reporters are fanning out to the hamlets and hollows of Middle America to find Trump supporters of modest means who would be disadvantaged by the president's budget and health care proposals. How, wonders the Washington pundit class, can Trump possibly reconcile his populist appeal with his efforts to simultaneously enact a upper-income tax cut and revoke health insurance from millions of less fortunate Americans?

Trump might bet that voters will reward bold policy change for its own sake, regardless of its specific consequences. Or, perhaps, he retains confidence in his ability to successfully sell anything he does to a segment of the electorate that he once claimed was so loyal that it would still support him even if he shot somebody in the middle of Fifth Avenue. It's also quite possible that he will deny responsibility for any unpopular provisions of the policies that he endorses, instructing voters to direct their blame toward Congress, the courts, or the federal bureaucracy.

Trump may be trapped between campaign rhetoric on one side and political realities on the other, but the entire Republican Party is in a similar predicament. The congressional GOP has also been forced to grapple with the challenge of suddenly fulfilling years of breezy promises to repeal the Affordable Care Act (and to replace it with an unspecified better, cheaper alternative) without spurring a popular backlash that could endanger its control of the legislative branch in next year's midterm elections. Today's health care debate is merely one example of a larger political problem that Republican leaders have faced for the better part of a century. Perennial conservative pledges to implement significant reductions in the scope of federal power are often frustrated by the inconvenient complication that even voters who say they don't like the government do like most of the specific things that the government actually does.

Trump the candidate was shrewd enough to recognize this fact, which is why he committed himself to maintaining current Social Security and Medicare spending levels while guaranteeing all sorts of other government-provided goodies to his supporters. But Trump the president will need to be even shrewder in order to escape voter anger for seeking to cut popular federal programs and benefits in contravention of his campaign-trail promises. The current occupant of the White House may be a newcomer to the conservative cause, but he has adopted its central ambitions as his own. Now he must reckon with the most formidable obstacles to its success.

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.

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.