How a conservative schism could break American health care

Now, it would be easy to caricature the second camp as heartless and callous, but even though I strongly disagree with it, I won’t do it. I have deep sympathy for my friends on the other side of the conservative divide who see an ever-expanding entitlement state and, essentially, Picard-like, draw a line in the sand and say, “This far, no further.”

Paul Ryan clearly belongs to the first camp. The problem is that a majority of his caucus belongs to the second camp — or rather, crucially, think (mistakenly) that their constituents belong to the second camp. This is why Ryan’s bill tried to please everyone, and thereby pleased no one. But the second camp is actually much, much smaller than the GOP establishment thinks. Donald Trump steamrolled his primary opponents by railing against ObamaCare and promising to replace it, not with some libertarian utopia, but with a system that would “take care of everyone.” He also defended his past support for single payer on the GOP debate stage, at seemingly low cost to his nomination.

The one virtue, I thought, of his election, was precisely that it had decisively settled this issue: The GOP now stood for universal health-care coverage, albeit through conservative means. That’s where both the base of the party and the party’s leader are. The problem is that Trump hasn’t shown the leadership and focus needed to turn this political victory into a policy achievement.