Efforts to repeal the Affordable Care Act have collapsed again, although it’s difficult to tell whether Senate Republicans will keep trying to find some way of passing legislation or whether they will simply do nothing and move on ― a strategy that President Donald Trump has already said he endorses because he remains convinced that Obamacare will collapse on its own.
But there’s another way to proceed. Republicans could work with Democrats on a narrow, bipartisan bill that would fix the Affordable Care Act’s very real problems while leaving the bulk of the policy edifice in place.
Until recently, the idea has mostly been the subject of whispers ― and wistful ones at that. But perhaps the most intriguing news Tuesday was an announcement from Lamar Alexander, the GOP senator from Tennessee and chairman of the health, education, labor and pensions committee. He said he intends to hold hearings on the Affordable Care Act’s insurance markets ― assuming that the Senate rejects the GOP “repeal-and-delay” bill when it comes up for a vote early next week.
It’s a signal that Alexander is open to the idea of passing legislation in the traditional way, with a slow, deliberative process ― and with real opportunities to find common ground with the other party. His Democratic counterpart, Patty Murray of Washington, quickly issued a statement reaffirming her party’s interest in such talks.
Of course, as a substantive proposition, bipartisanship has always had a compelling logic. The problem has been the politics for Republicans, particularly the fear that giving up on the repeal agenda and finding common ground with Democrats would be tantamount to admitting failure.
It’s a legitimate concern. But sometimes admitting failure isn’t the worst option on the table. For Republicans, who are now staring failure squarely in the face, this would seem to be one of those times.
Bipartisanship Would Mean Giving Up On Repeal
To be clear, Democrats won’t even think about bipartisan legislation unless Republicans start off by dropping huge swaths of their agenda.
Medicaid changes would have to be off the table entirely. Cuts to subsidies that help people buy private insurance would also be out of the question. The taxes that the Affordable Care Act imposed on the wealthiest Americans, in order to finance its coverage expansion, those would not be part of the negotiations either.
That would leave just one major area to discuss. It’d be the reforms of the private insurance market for people buying coverage on their own ― that is, the new regulations on who and what private policies must cover, and the operation of exchanges through which people can buy policies and get those subsidies.
These provisions are the parts of the Affordable Care Act that have caused the most anguish and controversy, mainly because insurers, no longer able to sell skimpy policies or to deny coverage because of pre-existing conditions, raised premiums.
Those changes have been a boon for millions, particularly those with pre-existing conditions, who can get comprehensive policies that insurers once refused to sell them, and those with relatively low incomes, who can now buy insurance that used to be beyond their means. But millions who don’t fall into those groups are paying more for coverage that’s worse (or at least feels worse), and some are simply not buying insurance at all, choosing instead to pay the individual mandate penalty.
This has made it difficult for insurers to cover their costs, causing some to pull out of markets altogether, which has left some parts of the country, particularly rural areas, with limited choices of high-priced policies.
Addressing these problems would not be particularly difficult. The essential ingredient is more money to subsidize directly or indirectly the people with the highest medical bills ― the ones that, previously, insurers were able to avoid covering. The money could take the form of new tax breaks to help people pay their premiums and deductibles, or it could be some form of “reinsurance,” which is basically a subsidy to help insurance companies cover the costs of their most expensive customers.
Democrats and Republicans each have their preferred policy choices. But they are not incompatible, and it’s easy to imagine the parties coalescing around a small subset of both.
The Senate bill that GOP leaders just abandoned included $182 billion for shoring up state insurance markets, including $50 billion dedicated to a reinsurance program. When Hillary Clinton ran for president, her agenda included $250 billion in new tax breaks to help consumers pay premiums or out-of-pocket costs.
Somewhere in there is a compromise. It might not be enough to fix all of the Affordable Care Act’s problems, but it could still mitigate them significantly.
If talks went well and the parties were feeling ambitious, they could even try discussing some bigger ideas, like allowing states to experiment with different regulations or alternatives to the mandate, perhaps in exchange for opening up Medicaid or Medicare to more people.
Every Option For Republicans Has A Political Downside Now
Republicans fear that conceding on full repeal, after so many years of promising it, would have some major political repercussions: incurring the wrath of some high-profile, well-funded conservative groups and depressing turnout in the 2018 midterm elections.
Those Republicans are probably right. But the alternatives carry some serious political risks, ones that the party’s officials and strategists may not fully appreciate.
Trump seems to think that voters won’t hold him responsible for problems in the new markets, whether it’s the ones he inherited because of the Affordable Care Act’s shortcomings or the ones he has created by neglecting or even sabotaging the law. “I’m not going to own it,” Trump said Tuesday.
In reality, an unhappy electorate almost always blames the party in power, and that means, more often than not, blaming the president. Current polling suggests the same thing would happen now. By a nearly two-to-one margin, respondents to a Henry J. Kaiser Family Foundation survey this spring said they would hold Trump and Republicans, not former President Barack Obama and Democrats, responsible for what happens to their health care.
Meanwhile, polls also show the public strongly supports bipartisan action ― and if Trump were to sign a bill, flanked by Democratic and Republican lawmakers, he’d get the kind of signing ceremony he so obviously craves. He’d even look like he was governing.
Alternatively, Republicans could still try to pass repeal legislation, whether it’s some version of the bill Senate leadership first proposed in late June or a “repeal-and-delay” proposal like the 2015 bill both chambers passed (and that Obama vetoed). The problem with either proposal is that, although some people would be better off, millions would end up without insurance while millions more would face higher out-of-pocket costs or premiums.
Republicans who have spent the last seven years soaking up right-wing propaganda, with its emphasis on everything that has gone wrong with Obamacare and virtually no attention to what has gone right, may still not fully realize how devastating those losses will be, although, from the looks of things, a handful of senators from states including Nevada, Ohio and West Virginia, where the coverage expansion has done wonders, understand just how much is at stake.
Not surprisingly, it’s some of these senators who offered the most vocal criticism of GOP repeal efforts and on Tuesday were the ones to reject a last-minute effort to pass “repeal and delay.” They have also been among the GOP senators expressing the most interest in starting up talks with Democrats.
Democrats Would Probably Be Willing To Negotiate
And the interest is clearly mutual. Allowing a devastating repeal bill to pass could very easily help Democrats in the midterm elections, and beyond, by energizing core Democratic voters and making it clear to the rest of the country, including a whole bunch of Trump voters, that GOP promises to bolster the safety net are flat-out false. Successful bipartisan legislation, on the other hand, would prove Republicans are capable of governing after all.
But expanding access to health care is so fundamental to Democratic Party identity that many members ― on both its left flank and in the middle ― would give away those political advantages if it meant shoring up insurance markets where they are floundering, so that fewer people were struggling with premiums and out-of-pocket costs.
If bipartisan legislation passed, each party could still pursue its broader agenda on health care. Republicans could keep trying to cut taxes and to contain or shrink federal programs, including Medicare and Medicaid. Democrats could keep promoting a larger government role in health care, whether through the gradual expansion of existing public programs, new efforts to drive down the price of medical care or a wholesale switch to a single-payer program.
But, for now, both sides could pocket a win and, more important, fewer people would have to go to sleep worrying about medical bills. The opportunity is there ― if only GOP leaders would be willing to take it.
Before You Go
