Why Republicans can't agree on health care

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Lost amid the political implications of allowing certain Obamacare subsidies to expire is the fact that this is Year 17, and counting, of Republicans failing to agree among themselves on health care policy.

The political implications matter, of course. That phrasing - "political implications" - is clinical, Washington-speak for roughly 22 million Americans being on the verge of losing an additional layer of federal assistance first made available during the coronavirus pandemic, without which their health insurance premiums will skyrocket. Some significant percentage of these people, who purchase policies on the Affordable Care Act exchanges, won't have the cash to cover the higher cost and will be forced into less generous coverage or none at all. Republicans are not indifferent to the impact this will have on voters and their families, nor clueless about the backlash it might precipitate in the 2026 midterm elections.

But Republicans in the House of Representatives and the US Senate are paralyzed by internal divisions over what to do about health care, and that has a lot to do with why Congress recessed for the holidays without approving legislation to address the insurance cliff created by the expiration of these "enhanced" pandemic-era subsidies.

It's been this way since 2009, when the debate began over the legislation that would become President Barack Obama's signature health care overhaul.

"The reason why Republicans can't coalesce around a proposal is because it's hard; it's really hard. This is a difficult issue," Charlie Dent, a Republican former congressman from Pennsylvania, told me, explaining that health care reform is complicated, politically risky and generally requires writing new government regulations and appropriating fresh sums of taxpayer dollars. None of that, especially the latter two, is especially appealing to Republicans on Capitol Hill (nor has it been particularly appealing to President Donald Trump during his first and now second stint in the White House).

Dent would know. He served from 2005 through the spring of 2018 and was around for the early Obamacare wars. About the only thing Republicans managed to agree on back then was their opposition to the Affordable Care Act. But even that unity had dissipated by the time Trump assumed office in 2017. Republicans, then with control of the House and Senate, failed to repeal and replace Obamacare because ultimately, they couldn't agree on the "replace" part of that equation.

Nearly a decade later, they still can't. But they do have some ideas. Over the years, Republicans have offered and supported various alternatives to the Affordable Care Act (or elements of the health care system established by the 2010 law). Some proposals have been ambitious in scope; some have tinkered around the edges.

Earlier this month, Republican Senators Bernie Moreno of Ohio and Susan Collins of Maine - a Trump acolyte and a centrist, respectively - pitched legislation that would extend the enhanced ACA subsidies for two years before transitioning policyholders to a reformed assistance program. Just last week, House Republicans on a party line vote approved the Lower Health Care Premiums for All Americans Act, legislation aimed at increasing the amount of low-cost insurance options available to consumers.

But the Moreno-Collins legislation didn't go anywhere, and the House GOP's bill will not get through the Senate precisely because it does not include an extension of the expiring ACA subsidies. Yet again, Republicans were stymied not by a lack of ideas but by an inability to reach consensus.

Some traditional Republicans simply can't bring themselves to embrace federal expenditures for a social welfare program that has put the government in charge of a substantial portion of our health care system. Meanwhile, some of the Republican populists who have become more prevalent in the Trump era are advocating exactly that, noting that many of the voters who backed the president in 2024 are dependent on these subsidies.

"They may want to take a more governmental approach - that may be the more populist thing to do," said Doug Heye, a Republican operative in Washington who served as a senior House GOP aide in the early 2010s, when the party's struggle to agree on an Obamacare alternative became apparent. "Others want a more free-market approach to it."

"The truth is," added Alfredo Rodriguez, a Republican media strategist in Texas, "victories outside of tax cuts often come incrementally." His solution to break the political logjam: Try passing a series of bills Republicans can agree on to create the momentum to tackle policy challenges that are difficult.

Democrats generally have had an easier time unifying around a single health care policy because they're comfortable spending government money and at ease with expanding government's reach into American industry. It's why House Minority Leader Hakeem Jeffries of New York was able to unite his caucus behind a discharge petition that will force a vote on extending the subsidies, courtesy of four House Republicans from competitive districts who signed onto the bill, giving it the 218 votes needed to proceed to the floor.

Might Republicans defy history and come together on a plan to extend these subsidies? It could happen. If they name the bill the "Trump Saved American Health Care Act," it might actually get signed into law.

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David M. Drucker is columnist covering politics and policy. He is also a senior writer for The Dispatch and the author of "In Trump's Shadow: The Battle for 2024 and the Future of the GOP."