A Short Vade Mecum for the Courtier-Technocrat in the Age of Trump

Should-Read: Reading the thinking of the Republican legislative caucus is always difficult, because they:

  • are terrified of getting turfed out at the next election (more terrified of the primary than the general, but still);
  • are not focused on the idea that policies need to work to be politically popular in the long run;
  • have a circle of advisers largely limited to those who have told them what they wanted to hear and what was politically convenient for them to hear in the past.

Thus standard technocratic reality-based habits of thought often do not apply. Here, however, Austin Frakt finds Lamar Alexander getting it.

I would add that a great many Republican governors who have the Medicaid expansion money would like to keep it, and a great many Republican governors who do not have the Medicaid expansion money would like it block-granted to them:

Austin Frakt: Senator Lamar Alexander and Endless Can-Kicking Repeal: Senator Lamar Alexander understand how hard crafting health policy is...

...said replacing Obamacare could take longer than the education bill he worked to pass last year, which took six years:

That was hard, but this is even more difficult because we spent six years as the Hatfields and the McCoys adopting our positions and shooting at each other. So building consensus in an environment like that is hard to do. But if we keep in mind that we’re trying to help people who are hurting and trying to keep people from being hurt, then that will encourage consensus.

More than six years! Making predictions in this environment is a fool’s errand, but I’ll do it anyway. I expect repeal with delay will happen by reconciliation. But the delay will be two years.... Then... there will be no GOP replace plan in time. What then? Either Congress will kick the can and delay repeal further or key parts of the ACA will expire. This process will repeat itself indefinitely.... If the GOP cannot craft a plan in two or so years, they will never do so. Never. Each election cycle will be too disruptive. A health care bill is much harder than an education bill. If you haven’t noticed, health care is a third rail onto which primary and general election opponents attempt to push one another. Endless, can-kicking repeal will be the best, achievable alternative.

But the uncertainty is terrible for insurers, as well as hospitals and state legislators trying to manage Medicaid programs. Repeated delayed repeal will probably lead to states with no marketplace insurers, a cessation if not retrenchment of Medicaid expansion, and will threaten the movement toward value-based payment. Senator Alexander may get this, but I’m not sure the rest of his caucus does.