Pat McCrory auditioned for the role of right-wing pugilist by headlining anti-Obamacare rallies. With the bitterness of a Tax-Revolt activist, he decried the intrusion of liberal meddlers into the private space of American healthcare. Could you imagine if healthcare became like the DMV? he queried. The performance was bravura, and it secured his hold on the full spectrum of Party conservatives.

Anti-government fulminations were ubiquitous in the Obamacare debate. It was the peak of the libertarian mood on the right, and grassroots conservatives across red America partook in the rhetoric of Jefferson, Coolidge, and Goldwater. These anti-statist sentiments found their most potent expression in conservatives’ feral terror at the prospect of greater government involvement in American healthcare, or so they claimed at the raucous and often-menacing rallies that presaged the famed gatherings of the Trump era. This small-government dogma was, they insisted, the core philosophical tenet of conservatism.

A decade and a half later, Republican healthcare policy has rendered all their old rhetoric a farce. In the same states that once seethed with anger against the Obamacare leviathan, Republican legislators are enacting blunt government bans on important healthcare procedures. There is no medical basis to any of this. In fact, the relevant medical authorities–gynecologists in the case of abortion, pediatricians with regard to gender-affirming care–strongly oppose GOP restrictions on their ability to perform these procedures. What, instead, brought forward the illegalization of key health services for women and the trans community is the cultural agenda that motivates nearly all right-wing activism in this nation.

Healthcare conflicts with conservatism; therefore, healthcare will meet with the stern hand of government.

Even in the Tea-Party era, conservative overreach into the sphere of medicine was not unheard of. The conservative attack on Obama was not limited to a focus on limiting the role of government in healthcare provision. In some circumstances, conservatives anticipated their later assault on culturally disfavored healthcare procedures. Led by Rush Limbaugh, the Tea Party clearly burned to illegalize contraception for young women. And Mitt Romney took an unambiguous stand for overturning Roe v. Wade.

Still, the conservatives of that time were not quite as authoritarian as they have become in their Trumpian incarnation. (It’s the same group of people.) While gender-affirming care absolutely took place in American hospitals back then, it was not a major subject of debate because trans people were still largely invisible. I do not, however, think it would have been guaranteed that Tea Party conservatives would have sought a ban on care for transgender youth. They’ve moved far in the direction of domestic autocracy.

But there is more continuity than meets the eye. The most important conservative slogan, then and now, was “Get your government hands off my Medicare!” Easily mocked, this outcry revealed that conservatives are perfectly comfortable with a government role in American healthcare. They have to be: As Nobel Prize-winning economist Kenneth Arrow explained decades ago, medicine cannot function as a free market. Conservatives libertarianism in healthcare is really about their strong opposition to aiding the poor. When government can impose conservative precepts on women and minorities, it acts with legal force. When government threatens to alleviate the suffering of poor people conservatives regard as undeserving, its machinations are a way to oppress the white Republican volk.