As the dust settles around the wreckage of the latest Senate Republican effort to “repeal” and replace the Affordable Care Act, learning from political failures should take priority over placing blame. Deep structural issues have caused Republicans to continue to struggle on health care, and addressing those issues will be a way to make a health-care-reform effort that will be more popular and deliver on key policy goals. Here are five lessons that might be learned:
Make the health-care debate about the future — not the past: The goal of the GOP on health care should not be turning the clock back to 2009, but improving medical care for 2017. Redressing some of the failures of the ACA will be part of that process of improvement, but eliminating the ACA alone will not be enough from a policy perspective (and, for the moment, that elimination seems fairly dead as a policy option).
Focus on expanding health-care options: We live in a time of great socioeconomic anxiety (which is one of the reasons why Donald Trump was elected president), and because of this anxiety, voters have an increased wariness of any measure that would appear to cut health-care spending. Pushing through spending cuts on health care not only unifies the Democratic caucus, it also splits the Republican one. For a number of reasons, Republicans are at their weakest when they try to govern as the party of austerity, but they are in a far stronger position as the party of the market. There are plenty of steps that Republicans could take to make the medical marketplace more flexible and fluid: diversify medical licensing, increase access to medications, eliminate cartel-like behavior in the medical industry, allow a broader range of insurance products to be sold, and so forth. A proposal that retains many of the ACA’s medical subsidies while also expanding and diversifying the health-care marketplace could prove popular while also advancing the principles of the market.
Go bipartisan: On health care, 60 votes might be easier to get than 50. Trying to push through health-care reform on a party-line vote limits Republicans to reconciliation, which means that their efforts at health-care reform will mostly have to be confined to finance, which is precisely the most politically toxic area for the GOP. The Democratic party might have partisan incentives to frustrate any prospect of legislative accomplishment for Republicans, but Democratic centrists might have a hard time resisting middle-of-the-road, market-oriented proposals to expand the range of health-care options. For example, proposals to increase funding for medical residencies, expand the range of over-the-counter medications and devices, and eliminate certificate-of-need laws could get strong bipartisan buy-in.
Remember that entitlement reform is distinct from health-care reform: Even under the best of circumstances, entitlement reform is a tightrope walk, but party-line entitlement reform is walking the tightrope while juggling chainsaws. Democrats took that walk in 2010 with the passage of the Affordable Care Act, and the party has some bloody stumps to show for it. Republicans are quite reasonable to want to avoid similar self-inflicted mayhem. Because entitlement reform can be so dangerous, Republicans might have to make a choice between trying to include entitlement reform as part of the health-care bill and passing a health-care bill at all. Medicaid could certainly stand reforming, but that reform will need some sign-off from congressional Democrats.
Expand the legislative map: There are many paths ahead for Republicans. They could try a return to repeal-and-delay. This strategy might face a tough legislative road, however; it seems unlikely that the GOP has 50 votes for repeal-and-delay. This strategy also only postpones an argument about what reforms will be necessary in the aftermath of the ACA, and if Republicans can’t put health-care reform in place before the period of delay, they will be held responsible by the public for all the ills that happen after the delay period. They might also try, as Ross Douthat has suggested, going small-bore on health care by making minor but popular modifications to the ACA. More targeted measures might slowly advance the ball in the right direction (a far better option than giving the other team an easy interception). Perhaps they could consider the proposal by Lindsey Graham and Bill Cassidy to distribute federal funds to the states and let them design their own health-care systems: Some might be more statist, while others might embrace free-market principles. And Wyden-Bennett, an old proposal from the pre-ACA era with a strong bipartisan credentials, might remain an option, too.
More targeted measures might slowly advance the ball in the right direction (a far better option than giving the other team an easy interception).
The debate over health-care reform has now dominated the first quarter of the 115th Congress. Much of this debate has been about how to stand the political pain of passing an unpopular bill on a party-line vote. With some imagination and legislative diligence, though, Republicans could find themselves in the much better position of trying to share the credit for making measurable improvements to the health-care system.
— Fred Bauer is a writer from New England. He blogs at A Certain Enthusiasm.