President Trump has tasked three Republican senators with coming up with a replacement for Obamacare if courts strike it down. It’s a prudent contingency plan. Republicans should, for that matter, advance their own health-care plan even if the lawsuit fails — as it is highly likely to do, in part because it lacks legal merit.
Republican senators are not notably eager to take up this assignment; their leader Mitch McConnell has suggested that the Senate will wait for the White House and the Democrats to reach a deal before it tackles health care. Republican strategists say the senators are right: Why put forward a plan and open Republicans to attack over it, when the party can concentrate instead on making the case against Democratic proposals to kick Americans off their health insurance and move toward a government monopoly? Why should Republicans reprise the experience of 2017–18, when they bled public support while trying to pass a health-care bill, spent the next election on the defensive on the issue, and then lost dozens of House seats?
A flaw in this cynical calculation is that Republicans cannot prevent Democrats from attacking them over health care by abandoning the issue; if that strategy worked, the 2018 elections would have gone very differently. Most of the Republicans who will be running for office in 2020 have already gone on record wanting to replace Obamacare. The Republican administration is urging its abolition in court. Democrats already have enough warrant to accuse Republicans of seeking to eliminate a health law on which many millions of Americans rely. Republicans can choose whether to respond to that attack by pointing to their own plan, or by letting Democrats devise a caricatured conservative plan to tie to them.
It is true that especially in the event the lawsuit fails, no conservative health-care plan has a chance of passage through a Democratic House. There is not much chance even that a conservative plan can serve as the basis for a bipartisan compromise. Note, however, that it was considerations much like these that kept Republicans from settling on a health-care plan during the Obama administration: They did not want to take responsibility for legislation they had no way to enact. The consequence was that when they had the power to enact legislation, they were unready to do it. They had built no consensus among Republican politicians or voters.
Obamacare’s key innovation was not the subsidization of Americans’ health-insurance purchases, an enterprise in which the federal government had been engaged for decades, albeit on a somewhat smaller scale. It was the centralization of health-insurance regulation in Washington, D.C. It is that centralization, and accompanying curtailment of choice and raising of costs, that Republicans tasked with replacing Obamacare should now work to undo.
They should propose that the federal government both remove many of Obamacare’s regulations and redirect the money now flowing to Obamacare’s exchanges and its Medicaid expansions to state governments, which would then determine how to spend it to meet their residents’ health-care needs. Under such a proposal states would be able, for example, to take some of the money that they currently spend on able-bodied Medicaid recipients above the poverty line and devote it to recipients who are disabled, below the line, or both. They could let Medicaid recipients use a share of the Obamacare money to buy insurance on the private market. They could try to increase coverage rates among the young by allowing insurers to give them discounts. And so forth.
Republican officeholders who want to modify this basic template or advance a wholly different idea should be encouraged to contribute their ideas. What is most important is that Republicans not ease into the posture of merely holding off the next Democrat-led lurch to the left for a few years, and that conservatives not let them. As unhappily as it has been received, President Trump’s challenge to his party is a welcome one.