Republicans’ Narrow Health-Care Window

W hen the Supreme Court rejected a long-shot challenge to Obamacare last month, it closed off the last remaining avenue to take down the law. The event should force Republicans into a long-overdue conversation about what approach to health care they want — and they should have it before Democrats strike again.

Over the decades, health-care policy has followed a familiar pattern. Liberal activists are passionately engaged with the issue and push Democrats to expand the government’s role in the area, while Republicans are mostly bored by the subject and tend to get fired up only when it comes to opposing Democratic initiatives.

After Hillarycare went down in flames in 1994, Democrats sought ways to make incremental gains (such as passing the State Children’s Health Insurance Program), and they studied their mistakes, plotting for the next time they took power with large enough majorities to address the issue. Republicans, meanwhile, alternated between ignoring the issue or coming up with watered-down alternatives. George W. Bush’s Medicare prescription-drug legislation, for instance, included some free-market elements, but it also represented the largest expansion of entitlements since the Great Society. As governor of Massachusetts, Mitt Romney pursued a regulate-and-subsidize model that became the basis for Obamacare.

When Democrats retook power, they used it to get Obamacare across the finish line. Republicans rode the backlash against the law, making repeal a central part of their agenda over the course of four election cycles. Yet they never actually used their time out of power to flesh out how they would advance their own health-care goals. And so, when finally given full control of Washington in 2017, they balked on repeal. Additionally, in multiple tries, the Supreme Court was never willing to kill the law.

So now Republicans find themselves in a bit of a holding pattern on health care. There is clearly no appetite within the GOP to repeal the entire law — which is even more entrenched than it was in 2017 — and yet, Republicans aren’t willing to acknowledge that reality out loud, and so they have not really grappled with what they should be doing now. Most Republicans ignore the issue altogether, while some have tried to convince themselves that reducing the individual-mandate penalty to $0 and eliminating some taxes constituted fulfilling their pledge. In a laughable passage in his memoir, John Boehner delusionally claimed, “There really isn’t much of Obamacare left.”

Republicans, however, seem to have lucked out about one thing. For the time being, it appears that Democrats have no interest in pursuing another sweeping piece of health-care legislation in the immediate future. The infrastructure and reconciliation bills are consuming all of the energy in Washington, and health care has moved down the priority list.

It’s true that President Biden’s “COVID relief” legislation expanded Obamacare by making its subsidies more generous and that he wants to use the reconciliation bill, in part, to make that expansion permanent. In effect, what this means is that Democrats have for the time being settled on a strategy of funneling hundreds of billions of additional dollars into the insurance industry. While this should be opposed by Republicans, given the scope of the health-care debate during the Democratic primaries, this is a rather major climb-down. Remember, one of the defining fights among Democrats concerned whether to eliminate private insurance and spend $34 trillion migrating to a fully government-run insurance system. In this debate, the “moderate” position advocated by Biden involved creating a new government-run plan within Obamacare, expanding Medicaid, and lowering the Medicare eligibility age. None of those policies is part of Biden’s current proposals.

While Democrats, in theory, want to pursue a more expansive health-care legislation in 2022, that is unlikely to happen, for several reasons. They lack the support to blow up the filibuster, and the Senate parliamentarian has effectively put a cap on the number of reconciliation bills they can pass. Also, health care will have to compete with other Democratic priorities, and it’s hard to believe Democrats would want to invite a brutal legislative fight that would divide their caucus during an election year.

That means that Republicans likely have a narrow window to recalibrate their health-care strategy before Democrats gain sufficient power to make their next major push. If Republicans want to avoid another major loss on health-care policy, they need to act now.