If the Republican Party’s crusade to repeal and replace the Affordable
Care Act is truly over, Monday night provided a fittingly sudden and
chaotic ending. Early in the evening, two conservative Republican
senators—Mike Lee, of Utah, and Jerry Moran, of Kansas—issued statements
saying that they wouldn’t support the revised health-care-reform bill
that Mitch McConnell, the Senate Majority Leader, released last
Thursday. Since the Republicans have a majority of just two in the
Senate, and two other Republicans—Susan Collins, of Maine, and Rand
Paul, of Kentucky—had already announced that they wouldn’t vote for the
legislation, the effort to secure its passage looked lost.

For several hours after Lee and Moran’s announcements, McConnell issued
no public response. Then, around 11 P.M., he released a statement that
said,
“Regretfully, it’s now apparent that the effort to repeal and
immediately replace the failure of Obamacare will not be successful.”

But McConnell didn’t leave it at that. Instead, he said that the Senate
Republicans would now move to vote on repealing the A.C.A. immediately
and dealing with the consequences later. Since those consequences would
include causing turmoil in the private markets and reversing the
Medicaid expansion that has provided health-insurance coverage to about
fourteen million Americans, it seems very unlikely that McConnell will
be able to get fifty votes to pass such an irresponsible piece of
legislation.

It wasn’t immediately clear whether McConnell really believes such a
reckless strategy is feasible, or whether he was simply looking to save
face. President Trump, however, supports pursuing repeal without
replacement. On Monday night, he tweeted,
“Republicans should just REPEAL failing ObamaCare now & work on a new
Healthcare Plan that will start from a clean slate. Dems will join in!”
That final sentence was almost certainly wishful thinking. And the
entire statement was consistent with the lack of gravity, inattention to
detail, and political gamesmanship that has characterized the Republican
effort to undo Obamacare since the beginning.

The larger lesson of this sorry episode is that nobody—not McConnell, or
Trump, or House Speaker Paul Ryan—can resolve the contradictions of
today’s Republican Party. Once the political arm of the Rotary Club and
the affluent suburbs, the Party is increasingly one of middle-class and
working-class voters, many of whom are big beneficiaries of federal
programs, such as Medicaid and the Obamacare subsidies for the purchase
of private insurance. But the G.O.P. remains beholden to its richest,
most conservative donors, many of whom espouse a doctrine of rolling
back the government and cutting taxes, especially taxes applicable to
themselves and other very rich people. It was the donors and ideologues,
with Ryan as their front man, who led the assault on the Affordable Care
Act.

These efforts had put several senators in a difficult place. Moran, who
was first elected in 2010 and has a solidly conservative voting record,
found himself being forced to defend a set of reforms to Medicaid that
meant potentially closing many rural hospitals and taking health-care
coverage away from more than a hundred thousand of his fellow-Kansans,
according to the Urban Institute. Although Moran cast his decision not
to support the revised bill in terms of needing more time for
consultations and legislative deliberations, it was clear that he was
feeling the political pressure.

In their statements on Monday night, both Moran and Lee said that the
revised bill didn’t go far enough in repealing the Affordable Care Act
and reducing premiums. This, despite the fact that the measure contained
an amendment—modelled on a proposal by Lee—that would have allowed
insurers to offer cheap, catastrophic care policies outside the
Obamacare insurance exchanges, so long as they also offered a
comprehensive option through the exchanges. In recent days, insurers
warned that the amendment was completely unworkable and could lead to
the collapse of the exchanges. How much further does Lee want to go? In
his statement,
he also referred to the bill’s failure to abolish all the taxes that the
A.C.A. introduced—taxes that only hit the donor class. In other words,
the bill didn’t do enough for the wealthy.

Moran, for his part, said, “We must now start fresh with an open legislative process to develop
innovative solutions that provide greater personal choice, protections
for pre-existing conditions, increased access and lower overall costs
for Kansans.” But in order to enable people with preëxisting conditions
or modest incomes to obtain health coverage at a reasonable cost, you
have to restrict the choices of others. The young and the healthy have
to be persuaded, or forced, to join the same risk pools as older and
sicker people. Insurers have to be prevented from creaming off low-risk
customers into separate markets. Rich people have to be taxed to pay for
Medicaid, or for the subsidies that enable working families on modest
incomes to buy private insurance. As Milton Friedman noted long ago,
there is no free lunch.

Obamacare, for all its complexity and teething problems, was, and is, a
serious and comprehensive effort to face up to these difficulties and
trade-offs. The Republicans never got serious about how to replace it.
They are now paying the price.