For eight years the Republican Party far too often defined itself by what it was against instead it was for, resulting in a party with deep ideological fissures. Despite Republican opposition to the process that resulted in the Affordable Care Act, current approaches to health care reform seem to have been even more partisan and closed off, with no significant work done in bipartisan committees, no hearings, and an explicit refusal to receive input from the Democratic Party.
And, of course, the Affordable Care Act (ACA) was already an approach to health care reform that sought to incorporate conservative values. It contained many ideas proposed by the Republican Party in the early 1990s in a bill that included co-sponsors such as Bob Dole, Charles Grassley and Orrin Hatch. That Republican plan included the creation of purchasing pools with standardized benefits, a ban on denying coverage based on pre-existing conditions, vouchers for the poor to purchase insurance and — believe it or not — an individual mandate.
It also differed from the modern ACA (it did not include Medicare reform and did include medical malpractice tort reform), but the point is that it demonstrates that a market-driven approach to health care is, at its core, a conservative approach.
If the ACA had been purely liberal invention, it would have been a move to entirely government-provided health care through taxes and regulation (the approach in almost every other developed country). If it had been a blend of liberal and conservative approaches, it would have included a public option, a government-run plan that would have been sold alongside private plans on the marketplace. But instead, many of the pillars of the ACA come from conservative answers to health care reform.
We are now seeing the results of this reality as the Republican Party has entirely failed to articulate (and, more importantly, legislate) a more authentically conservative approach to health care — particularly an approach that would have any popularity among the American people. The conservative ideas from the 1990s (pools with standardized benefits, ban on pre-existing conditions, etc.) remain the most popular concepts of health care reform. The only exception is the individual mandate — but economics is pretty clear that without an individual mandate, a purely market-driven approach will not produce significant cost savings.
So it should be easy, it really should, for Republicans and Democrats to come together and fix the ACA. The Brookings Institute has identified several actions that could be taken in a bipartisan approach: eliminate or improve the employer mandate, eliminate the excise tax on “Cadillac plans,” and instead change rules regarding health care and taxable income for those above certain thresholds, make it crystal clear that the federal government will stand behind Medicaid expansion, eliminate the unpopular Independent Payment Advisory Board, and expand assistance for low-income Americans struggling to pay for insurance.
Unfortunately, the Republican Party spent the better part of a decade fighting to repeal the ACA and replace it with something better.
The Trump administration is now threatening to hold the American people hostage, refusing to pay insurance companies the assistance required by the current law knowing that this would do tremendous damage to the marketplace. But that damage would not, of course, be borne by the Trump administration. It would be borne by the average American, who would see premiums skyrocket and who would have to pay those premiums until Congress came up with a better health care plan. And given the success of Congress so far, that cost will be likely borne by the American people for quite a while.
This is not governance. This is a battle plan.
And this is the key problem facing us as a country: Far too many people on both the right and the left are far more interested in winning than they are on making our country a better place. Obama’s legacy must be upended at all costs. Trump must be opposed at all costs. This kind of politics is quickly becoming a sort of mutually assured destruction.
If the Trump administration and the Republican-controlled Congress is smart, they will start focusing on a bipartisan reform of health care. Indeed, several Republicans have argued that this is the approach that should be taken. True, they will lose votes on the right wing of their party, those who only know how to fight for repeal and replace. But the votes they could gain from independents and moderate Democrats would mean we could finally see real change that actually helps the average American. If even including the words “repeal” in the title enables Republicans to pass it, but the content is indeed better for the American people, moderate Democrats should still support it. They shouldn’t fear that it will make it look like they have lost.
After all, if bipartisan health care reform is not passed in this current administration, I have a hunch of what will come next. Costs will continue to increase — maybe even at unprecedented rates if the administration truly does undermine the ACA. This will give the Democrats the increased political power they will need to introduce a public-option to the marketplace or, perhaps, begin the move to universal health care.
Personally, I would love to see that happen. I think it would be the right move for our country and would finally begin to reign in costs (as is the case in countries that already follow these approaches). The leadership of the Republican Party would likely fight this with every ounce of their being. But if they do not get to work fixing the ACA, they will have no one to blame but themselves.
The Rev. Dr. Jared C. Cramer, Tribune community columnist, serves as rector of St. John’s Episcopal Church in Grand Haven.