Republicans never thought they would be in this position.
The AHCA, The Republican plan to repeal and replace the the Affordable Care Act, is in trouble. The far-right hates the bill because it doesn’t go far enough to eliminate government subsidized health insurance for those who can’t afford it. Endangered Senate Republicans don’t like it because it goes too far. Speaker Ryan is now seeking Democratic votes to help him pass Obamacare’s repeal, even as Donald Trump is threatening Republicans who oppose the bill with primaries–even though the AHCA betrays most of Trump’s campaign promises about healthcare.
As this mess unfolds, it’s worth remembering that the Republican Party has had eight years since the passage of the ACA to consider what it would do instead, given control of all three branches of government. Eight years for all of its policy wonks to design a plan that would provide, in Trump’s words, “insurance for everybody” that is “much better and much less expensive.”
The problem is that the only way to provide better, less expensive care for everyone that improves on the ACA is the universal, government-backed insurance offered by nearly every other developed country in the world. Allowing insurers to sell across state lines would create a regulatory race-to-the-bottom and do almost nothing to lower costs. Most Americans have so little in savings they can’t retire or put their kids through college, much less cover $500,000 of cancer treatments through an HSA. And covering people with pre-existing conditions through market processes requires a mandate to make it work.
Republicans know all of this. They know it because the ACA is actually the conservative, market-based alternative to single-payer. It was essentially was the Heritage Foundation’s alternative to Hillary Clinton’s 1993 healthcare plan. It became the basis of Romneycare, the plan backed and enacted by the 2012 Republican nominee for president. It’s the Republican alternative to single-payer.
That Republicans have been so adamantly hostile to it represents jaw-dropping political hypocrisy and opportunism. The pre-Obamacare status quo theoretically served their donors better because it contained fewer taxes on the rich, but it was also an escalating national crisis that needed solving. The lack of a Republican solution on healthcare was a big driver of Democratic votes. But rather than be a responsible partner in fixing the problem in a way that pleased conservatives as much as possible, Republicans played political gamesmanship. They called their own plan a socialist abomination with death panels. They scared seniors into thinking that their own Medicare would be snatched away in order to give healthcare to the unworthy–even as they plotted to defund and privatize Medicare themselves. It was a con of breathtaking proportions, and it worked. Lies, outrage and fear over the ACA were big drivers of the 2010 and 2014 Republican wave elections from which the Obama Administration never recovered.
But Republicans still don’t have an alternative plan for solving the healthcare crisis. They never did. That’s why the AHCA looks so much like the ACA, only stingier and less competent. The true believers on the far right want a fully libertarian system, but the more sober folks in leadership know the public health catastrophe that would cause would destroy Republicans electorally for a generation. The few Republican moderates want a GOP facelift on the ACA that doesn’t endanger them too much. Trump knows nothing about healthcare policy at all, and just wants to check off a box on his list of things to anger liberals about.
But none of them ever expected to be here, and they never had a plan.