As of Friday afternoon, the Republican healthcare reform plan is teetering on a knife's edge. Two Republican senators already declared their opposition to the latest bill, meaning one more no vote will kill it. And while that third vote hasn't materialized as of this article's publication, Republican senators have started to speak surprisingly openly about pursuing "Plan B," which is their euphemism for a bipartisan healthcare bill crafted with Democratic input.
Last Thursday, Senate Majority Leader Mitch McConnell stated publicly that if the current bill fails, he'd be willing to sit down with Democrats to stabilize the healthcare markets. By Monday, some Republicans were welcoming bipartisanship as a possibility. On Tuesday, Senator Lindsay Graham, weeks after saying he'd let the Affordable Care Act implode to force Democrats to work on his side's terms, announced plans to unveil a new healthcare proposal intended to entice Democratic support. And by Wednesday, senators from both parties were reportedly discussing ideas with McConnell's consent.
Democratic senator Tom Carper claims he's spoken with a third of the Senate GOP caucus on the issue by now. There's no actual bipartisan working group as of yet, but the winds of change are blowing strong.
Yet for all the vague chatter floating around the faltering Republican plan, no one has laid out a firm vision for what a bipartisan healthcare plan would look like. That's likely because, while lots of people like bipartisanship in theory, there's not much of substance for the two parties to coalesce around.
"It's not a matter of finding a hidden majority that hasn't had a voice because of partisanship keeping it down," said Thomas Miller, a health scholar at the conservative American Enterprise Institute. The way he sees it, the desire for bipartisanship just reflects an intra-party Republican impasse. But while a fresh start sounds appealing, "when you move over to doing something bipartisan, you'll find that those who thought there was a bipartisan agreement aren't getting as much of what they want."
The two parties don't agree on much when it comes to healthcare. Republicans have long campaigned, and in the past made symbolic votes, on totally repealing the ACA. Democrats have unified around the position that they won't come to the table unless all talk of repeal ceases. So bipartisanship would mean that Republicans give up a key policy that has united nearly every faction of the party.
Wonks on both sides of the aisle have come up with tons of ideas for tweaking the ACA that could appeal to both parties if all repeal plans fail due to Republican infighting. The goal of these plans usually being to stabilize the ACA's individual insurance marketplaces, which cover about 10 million Americans and which have seen drastic premium increases, insurer pullouts, and lower than expected enrollment since coming into being in 2014.
Republicans might want, among other things, to slide in cheaper catastrophic plans that don't cover all the services guaranteed in the ACA. Democrats want, among other things, to restore subsidies that were hobbled by Republicans but are meant to reimburse insurers for costs.
But shoring up subsidies strikes many Republicans as an immoral insurance sector bailout. And expanding them is out of the question for the bulk of a party that wants to cut non-military domestic spending in general.
"McConnell is the least sincere proponent of bipartisanship I can imagine."—Jacob Hacker
If Republicans did compromise, they'd be attacked for going too far left by primary opponents; at this point, anything short of full repeal would be regarded, probably rightly, as a major failure. While he has sent mixed messages on healthcare throughout this saga, President Donald Trump's current whim seems to be to punish anyone who wants to go bipartisan.
Democrats, meanwhile, might not be willing to budge far enough either. They've done quite well by standing firm against the entire Trump-Republican agenda. And there's a significant faction of liberals and leftists who want to dramatically expand government involvement in healthcare markets; those people aren't likely to cheer something that gives ground to the GOP.
Given these tensions, jaded observers read current calls for bipartisanship as symbolic or even threatening gestures.
"McConnell is the least sincere proponent of bipartisanship I can imagine," said Yale healthcare expert Jacob Hacker. The GOP leader's talk of sitting down with Democrats "is clearly a threat" meant to scare conservatives in his party to get in line with the current Senate bill.
"Bipartisanship is a talking point to position the GOP to later criticize Democrats for being 'obstructionists'" when nothing productive comes out of that process, argued healthcare politics wonk Larry Jacobs. It's posturing to take the final blame for failure off of Republican shoulders.
Yet when push comes to shove, the two parties could work out something. There are enough moderates in both camps worried about the stability of the ACA markets that they could collaborate on a solution. Republicans, who would clearly take the blame for any healthcare fiasco right now, could spin this as passing something rather than nothing and float the idea of returning to comprehensive overhaul ideas later. Democrats can say they forced the GOP to work with them, passing useful legislation despite being in the minority.
"Working with Democrats is dangerous," is how Hacker summarized likely Republican thinking. "Not passing anything may be even more dangerous."
As longtime healthcare policy watcher Sara Rosenbaum noted, no bipartisan chatter means anything until McConnell sits down with Senate Minority Leader Chuck Schumer. But such a meeting is possible if the ACA repeal doesn't get done by the August recess, even if McConnell's musings on the idea so far have been intra-party threats rather than outreach.
Experts I spoke to didn't think that the parties could pull off major legislation by working together—partisan rifts between them are just too wide in this Congress. They'd almost certainly only be able to agree on one very basic plan both sides have floated: Ensuring that cost-sharing subsidies for insurers on the ACA marketplaces are funded, which would likely prevent unsure providers from pulling out or jacking up their premiums. These subsidies already exist. It's just a matter of making sure they're permanent in order to reassure insurance companies.
"Now people seem to accept the fact that you have to work on market stability," no matter what side they're on, explained Rosenbaum of this narrow consensus point.
That'd be a sufficient fix in most respects. The ACA markets are already stabilizing after one giant premium increase made to correct for a lack of originally promised subsidies and differences between expectations and realities in a new, unknown insurance pool. Their remaining fragility, the key point on which Republicans and Trump have savaged the entire ACA in recent years, stems directly from uncertainty about the future of the markets under Republican rule. Scuttling the Republican plan, then putting guaranteed funding into extant subsidies, should bring more insurers into the market again and help even out or drive down premiums, even if that takes a year or two.
Not that that will satisfy most people. Conservatives will still blame the ACA for America's healthcare problems, from high premiums to the high cost of drugs. And liberals want either a single, government-run insurance system or at the very least an expansion of Medicaid or Medicare. Those issues are likely going to have to wait for the next Congress, though. Because this tiny fix is probably the best this one will be able to offer.
Follow Mark Hay on Twitter.