Republicans find themselves torn between two factions in considering the American Health Care Act. Even though it is theoretically possible both to expand health-care coverage and reduce government spending, one faction of Republicans prioritizes the first concern while another prioritizes the second.
Some Republicans are very skeptical of any health-care reform that would roll back the subsidies for health-care coverage granted under the Affordable Care Act. They fear that repealing subsidies could endanger access to health care for millions of voters — who could rise against the GOP in 2018 in a considerable backlash.
Other Republicans (including, I think, many members of the Freedom Caucus) in part oppose the Affordable Care Act because it increases government spending. From their perspective, the ACA is another instance of big government. This group of Republicans would seem very skeptical of any measure that keeps these subsidies.
Because of the thinness of Republican margins in the Senate, both groups would need to be at least somewhat happy with a bill in order for that bill to pass (assuming that one group does not just surrender its preferences). One way of doing that is try to reform the system of tax credits and subsidies so that overall coverage is not negatively affected by Republican-led health-care reform. That seems in many ways to be the road taken by the House’s American Health Care Act, which revises the ACA’s approach to subsidies and taxes for health care. Because the Congressional Budget Office has not yet scored the bill, there is no public estimate about how the AHCA would affect coverage (the concern of the first set of Republicans) and government spending (the concern of the second). The specific merits of the AHCA I leave to more expert minds than my own, though many conservative wonks seem fairly skeptical about the AHCA as it currently stands.
Another way out of this controversy would be to supplement a focus on subsidies with a focus on reforming regulations in order to expand access to medical care. Licensing reform as well as investigating the reform of things like Certificate of Need policies could increase the diversity of medical services available. The federal government and state governments could encourage an increase in the number of doctors. Opening up insurance markets could allow for more competition. Federal regulations for insurance companies could be revamped, as could prescription-drug policies. In order to expand health care and to cut costs, policymakers will have to use every arrow in their political quivers.
Looking at some of these regulatory issues could unite the GOP caucus and perhaps even bring over some Democrats. However, because Republicans want to be able to push through the AHCA via reconciliation, they can’t touch many of these regulatory issues with this piece of legislation. Because of this insistence on reconciliation, Republicans have to lead with the divisive and perhaps politically dangerous issue of subsidies.
The Affordable Care Act basically crippled the legislative agenda of Democrats during the Obama era — and Democrats had an even stronger hand in Congress in 2009–10 than Republicans do now. The GOP no doubt wants to avoid a similar run at the buzzsaw. How exactly to avoid that whirling blade obviously remains a matter of some debate on Capitol Hill.