The Republican Party controls the White House, the House of Representatives, the Senate, and a majority of state governorships and legislatures nationwide. One might think that level of political clout would make the transition process easier. But it doesn't, because the Republican Party also has a problem just as big as its 2016 electoral wins: When it comes to the issues that brought the GOP into power in the first place, its members — including the next president — can't agree on what to do next. And the split is putting the party's victories in jeopardy.
One wing of the GOP is run by Paul Ryan; the other is run by Donald Trump. One is conservative; the other is populist. One views government as an impediment to individual freedom; the other views government as a weapon to be wielded against the disloyal and disrespectful alike. The duality of the GOP is plainest when it comes to health care. Although the Affordable Care Act ("Obamacare") is more popular than it’s ever been, the GOP remains a party and a constituency that is dedicated to changing it (or killing it entirely). But though both sides seem to agree about getting rid of Obamacare, they differ — strongly — on what to replace it with. And they're sticking the party faithful, along with millions of American citizens, in the middle.
To conservatives, universal health care — that is, government-backed health coverage for all — is a bust, both financially and politically. They point to countries like Canada as proof that such a system would be a bad idea for Americans. Canada has what's known as a single-payer health care structure, a type of universal coverage where private doctors and hospitals provide care, from surgery to strep throat medication, that is paid for from a single "pool" of money. The government typically controls that pool, which comes from tax dollars. In short, if you pay taxes, your health care costs are covered. By contrast, in our current system, we pay insurers, who then pay our medical service providers (though we often pay "co-pays" to those providers as well).
Democratic presidential nominee Bernie Sanders was a major proponent of a single-payer system, but conservatives view such a structure (and universal health care in general) as too expensive and too limiting to private enterprise and personal freedom. The conservative Heritage Foundation reviewed state-run health care systems from around the world in 2006 and found that they necessitated higher taxes, frequently experienced funding problems, and required "authoritarian governance" to work. If the government controls medical care funding, the logic goes, it could control who gets care — and who doesn't. Hypothetically, Heritage worried, people could lose custody of their children on the basis of their adherence to health guidelines (if the child is overweight or obese, for example), or even be subjected to the fictitious "death panels" (in which doctors could decide which elderly or disabled people would receive medical support and which wouldn't) that Sarah Palin so famously warned of during the debates over the Affordable Care Act in 2009.
But that's not Donald Trump's perspective. In fact, our next president has said that the Canadian health care apparatus works just fine. He wants "insurance for everybody" — paid for by the government. And he's wanted that for years. In his 2000 book The America We Deserve, Trump wrote, "We must take care of our own. We must have universal health care," adding that "I'm a conservative on most issues but a liberal on this one." Even while blasting the Affordable Care Act during the presidential campaign, he said that "we're going to take care of people who are dying on the street" who lack health care coverage. Though Trump has given virtually no signs as to what a replacement for the Affordable Care Act might look like (or how it would ever be approved by Congress), he has claimed that it would keep the ACA's ban on insurers denying coverage to people with pre-existing conditions and allow parents to keep their children on their health care plans until their 26th birthday.
Although Speaker of the House Paul Ryan told a Wisconsin-based news outlet on Monday that he and Trump are totally on the same page, he says that the replacement for the ACA will not allow for universal health care coverage but for universal access to health care coverage. In Ryan's view, it's more important for Americans to be able to choose their own coverage than to be able to afford health care in the first place — like being able to choose between grocery stores, but not necessarily able to afford groceries. That's not universal health care coverage, and that's certainly not what Ryan's new boss has advocated again and again for the past two decades.
Of course, the divide between the GOP and its president is bigger than the debate over the future of the ACA and the American health care system. It's a strategic and ideological schism that threatens the success of the party as a whole. Conservatives who called the ACA "socialist" face the arrival of a new health care plan potentially even more extensive and expansive — and one wholeheartedly supported by a Republican president. Or they might have to defend a policy that forces more than 18 million Americans off their health insurance and drives up the costs for everyone. If Trump's policies continue to be more guided by polls than by politics, they're likely to be less reflective of Republican ideology than whatever is popular at any given time.
For example, Trump said after the election that despite months of rhetoric about "dangerous illegals," he might be inclined to support permanent residency for young undocumented immigrants living in the U.S. under the DREAM Act — against GOP wishes. His campaign efforts focused largely on pushing billions of dollars in infrastructure investment through Congress — a plan conservatives have dismissed as a waste of taxpayer money. Trump's views are often unclear even to his supposed allies, but in a political windstorm, he seems unable to point in any direction but the one most popular (except on Russia). That's bad news for conservatives, and for the Republican Party as a whole. What good is it to Republicans running against "big-government liberals" when you voted for one for president, from your very own party?
A replacement for the Affordable Care Act could arrive as soon as next week. But the debate over a potential bill and the disastrous ramifications it could have on America's financial markets — and, more importantly, on Americans themselves — will take months, perhaps years to understand. And the two groups most likely to clash won't be Republicans and Democrats; it'll be Republicans and other Republicans, caught between political expediency, popularity, and the very platform of the party to which they pledged allegiance.