Republicans haven't been able to replace Obamacare, because they think the problem with it, metaphorically speaking, is that the food is terrible and the portions are too small.
That, of course, is what Woody Allen had to say about life in “Annie Hall.” But the same kind of contradiction — you hate something, and want more of it — is why Republicans haven't been able to agree on anything other than that they want to be able to say that they repealed Obamacare. That might work on for campaigning, but, as we've seen, it's a flop in office. President Trump on Tuesday — in what's become something of a weekly tradition — again promised his party would strike a deal. But even if Republicans keep trying to come to terms on a compromise, they're going to keep tripping over the same problem. That's because no matter how much dealmaking prowess you might have, you can't make one if people want fundamentally different things.
Now, when it comes to Obamacare, there are generally two types of Republicans: ones who despise everything about it, and ones who understand nothing about it. The first group are libertarians who want to get rid of the law root-and-branch. They don't think the federal government should play any part in helping people get coverage, or telling insurers what that has to be. Instead, they'd like to go back to a world where the sick are mostly on their own, and insurance companies are mostly free to discriminate against them. This, together with higher deductibles, is what they believe is the best way to keep costs and premiums down for everybody else. The idea, you see, is that people will spend less overall if they have to spend more out-of-pocket, and if that's too much for them, they can always be put in a slightly subsidized high-risk pool. (Emphasis on the word “slightly.” The Kaiser Family Foundation's Larry Levitt says that “the technical term” for the funding in the GOP's latest proposal is “chump change.")
In other words, they want to make insurance more affordable for the young and healthy by making it unaffordable for the old and sick, and worse for everyone.
The second group are so-called moderates who oppose Obamacare entirely because of politics, not policy. Which is to say that they attack the unpopular parts of the law, like penalizing people for not getting insurance, at the same time that they support the popular parts, like banning insurance companies from discriminating against people with preexisting conditions. What they don't get, though, is that you can't have the latter without the former. If you're going to force insurers to cover sick people, then you have to force healthy people to sign up too so that premiums don't explode. And if you're going to force healthy people to sign up, then you need to help them be able to afford it.
And that brings us to the GOP's real problem. It's that a lot of Republicans secretly kind of like Obamacare, or at least they like what it does. They don't want to get rid of the way it's covered sick people or expanded coverage or let kids stay on their parent's insurance until they're 26 years old. The only thing they do want to change — well, other than the name and the individual mandate — is the way that premiums and deductibles have continued to march ever higher. But that, whether they realize it or not, is actually an argument that Obamacare hasn't gone far enough. That we need bigger subsidies so people can buy better coverage that doesn't make them pay as much out-of-pocket.
So how do you reconcile the idea that the healthy should pay more and the sick pay too much with the belief that the healthy should pay less and the sick be taken care of? You don't. At least not when you're in power. When you're out of it, you can at least hide these differences behind the amorphous mantra of “repeal and replace.” But not anymore, not when it's clear that there's a philosophical divide between Republicans who think the federal government shouldn't be involved in covering people, and ones like Louisiana Sen. Bill Cassidy who believe that “there's a widespread recognition that the federal government, Congress, has created the right for every American to have health care.” That used to be what Republicans and Democrats argued about, but, now that Obamacare has made people expect more from the government, it's what Republicans and other Republicans argue about today.
And there are going to be large portions of that.