When the Democrats took on healthcare reform after sweeping into power in 2008, they had a clear objective: Provide more people with health insurance. The Affordable Care Act, made law after more than a year of vote-wrangling and compromise, had plenty of problems. Drugs are still too expensive, some state insurance marketplaces are struggling, and the resulting system is overly complicated and insufficiently generous. Still, millions more people have insurance as a result of the ACA. But as Republicans, including Donald Trump, try to push their ACA replacement plan through the House this week, they don't have a similarly obvious goal. And that's a problem—both for the Republican Party and the country.
There's an obvious conservative way to reform healthcare, which is to just get the government out of it as much as possible. That argument is that it's not the federal government's job to provide health insurance to people who aren't old or poor, nor should the government force people to buy insurance they don't want or require insurance companies to offer specific benefits. Taking away the ACA entirely would deprive millions of people of insurance, and a lot more patients would get treated at emergency rooms—but a full repeal would at least be intellectually consistent with the conservative movement's anti-government rhetoric.
Some Republicans, like Kentucky senator Rand Paul, would like to see full repeal, but the party leadership doesn't endorse this argument. The American Health Care Act, House Speaker Paul Ryan's stab at reform, was in fact denounced by many conservatives because it didn't abolish the system established by the ACA, instead just providing less help to the poor and the sick.
So if a full ACA repeal is off the table, are there more limited but more specific reforms the Republicans want? What about the idea, beloved by Trump, to give insurers more freedom to sell plans across state lines? That's not in the current bill. (It's also not likely to save much money.) Hey, how about the far-right Freedom Caucus's notion to let states decided if insurers can charge more money to people with preexisting conditions? That part of the bill is making moderate House Republicans very concerned, and Ryan spent some time Tuesday confusingly (and wrongly) denying that preexisting conditions would be affected under the bill.
By Wednesday, House Republicans seemed to be attempting to compromise among themselves: States would be allowed to put people with preexisting conditions in "high-risk pools" in order to reduce costs on the rest of the system. These pools would receive billions in federal funding to subsidize the high cost of care, but traditionally high-risk pools have charged high premiums and might require more money than Republicans are willing to put into them. Healthcare groups and AARP are opposed to these pools, and it's not even clear that this compromise would secure enough votes to pass the House.
Making matters even more muddied, Trump has been going around saying that he actually wants to make health insurance plans more comprehensive and affordable, even as the bill he endorses would do pretty much the opposite (though it would make insurance cheaper for some healthy people). Other Republicans have complained about high deductibles under the ACA—but aren't actually trying to drive deductibles down. You can tear down the subsidies and regulations built into the ACA in the name of limited government, or you can change the law to give people more generous insurance coverage, but it's pretty much impossible to do both.
Back in January, the conservative journalist Matt Lewis had a column predicting this mess. "Every conceivable scheme or solution creates new problems," he wrote in the Daily Beast after talking to multiple right-wing healthcare experts. "None of them solve the problem because this problem is simply too complicated to 'solve.'" Instead of trying to reform the entire system, Lewis suggested, the GOP should try to put forth some modest ideas like letting people put money into Health Savings Accounts, tweaking the tax code to incentivize more people to buy insurance and letting insurers sell across state lines. You could object to these changes, but they aren't a matter of life and death the same way that the current debate is.
The problem here is that Republicans have been telling the country for seven years that the ACA is a disaster and needs to be repealed—tinkering around the edges wouldn't satisfy the party's right-wing base, and it would look pretty darn weak. Even with the White House and both chambers of Congress, you can't deliver on your number-one promise?
At this point, the debate is barely about policy. Trump seems outright indifferent to the details of the bill, and the last month has revealed a fundamental divide among Republicans about how much of the ACA should be repealed. Instead, GOP legislators are treating this as a purely political exercise. Moderates don't want to vote on a bill that would effectively force them to choose between taking away health insurance from sick people or keeping the ACA intact, either way a tough thing to explain to their voters. The conservatives on the Freedom Caucus just don't want to be known as the group who killed reform. Everyone in the House just wants to pass a bill, literally any bill, that can be called "Obamacare repeal" so that when it dies in the Senate it will be the upper chamber, not the up-for-reelection chumps in the House, who shoulder the blame. Trump wants—actually, who cares what Trump wants? Increasingly, Congress seems inclined to simply ignore him.
As I noted earlier, there are lots of problems with the ACA. Some of these have been pointed out by Republicans, and others are acknowledged by Democrats. The bitterest irony in all this is Trump is right: Too many Americans are paying high premiums or stuck on plans with deductables so high that they're basically worthless. Instead of fixing that, though, Republicans are wasting time on petty squabbling. We'll see if voters reward them for that in the midterms.
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