Trumpcare is all but dead, and the GOP effort to repeal Obamacare has a big elephant’s foot in the grave, at least for the time being. Either or both could return in a zombified form, but probably not right away.
So assuming nothing shocking happens this week, Democrats need to decide pretty quickly how they want to deal with the scorched earth the Republicans left. Do they just hold tight and build up their oppo-research files with the details of votes for damaging but dead bills? Do they come up with their own big counter-vision of health-care policy? Do they offer a peaceful hoof to the Republicans who are at least talking about a bipartisan health-care bill? And if so, how far should they be willing to go?
These are good and important questions for Democrats, but the first should probably be this: How badly do you want to “fix” Obamacare without transforming it into something very different? A growing number of Democrats now support some form of single-payer health-care system. There is virtually no chance that Republicans will help the country move in that direction. So if the grand idea is that Obamacare was an impure compromise with the evil of private health insurance, and that Democrats should campaign relentlessly on single payer in 2018 and 2020, there may be no reason to “do anything” substantive on health care at all. Yes, that would risk chaos and high premiums in the individual health-insurance markets, and real pain for real people, but perhaps Republicans fear being blamed for those terrible things enough to avoid the worst, without Democratic cooperation. It’s a morally risky, but politically sound strategy.
For those Democrats who cannot bring themselves to just walk away from Obamacare, there are three types of bipartisan action on health care that are potentially available, none of them mutually exclusive:
Stabilizing individual insurance markets. Obamacare is doing a lot better than most Republicans are willing to admit. But there are and have for a while been some problems attributable to poor guesswork on how both individuals and insurers would behave. The most immediate problem, however, is the legal limbo in which the so-called cost-sharing reductions (CSR) to insurers exist. This is a mechanism to keep out-of-pocket expenses for low-income people receiving insurance in the individual market from getting out of hand. Thanks to a House GOP lawsuit and occasional threats from Donald Trump to terminate payments, insurers have no idea whether they can count on CRS subsidies, and thus whether participation in Obamacare will be profitable. Regularizing these payments should be the first demand of Democrats in any bipartisan health-care initiative.
A second idea has actually been promoted as much by Republicans as by Democrats: using a reinsurance system or new funds for the states to deal with people in the individual markets who have exceptionally high health-care costs. This would reduce cost pressure on premiums for people who are healthier — a key objective of conservatives during the health-care debate — and reasonable pricing and predictable costs would make it easier for insurance companies to function. While reinsurance is an idea being promoted by a group of centrist House Democrats, there’s nothing about it that’s offensive to progressives.
Keeping the maximum number of younger and healthier people in insurance risk pools. One of the miscalculations in the original Affordable Care Act was how effective the individual mandate would be in keeping the risk pools supporting older and sicker people broad and representative of the entire population. Ideally, an Obamacare “fix” would strengthen enforcement of the mandate, though that would be more than a small reach during a Trump administration, particularly after years of conservative rhetoric about how un-American the mandate is. But every iteration of Republican Obamacare replacement legislation has created some alternative means of encouraging maximum use of health insurance by people who do not strictly speaking need it right now (e.g., higher premiums for late enrollment). Democrats could work with Republicans toward a package of effective measures, offering Republicans the trophy of replacing the individual mandate.
Broader nonideological reforms of the health-care system. Beyond the most immediate “fixes” in Obamacare, there are a few other ideas that most Democrats can support and that might appeal to enough Republicans to form a majority in the House and the 60 votes necessary for bipartisan legislation in the Senate.
Republicans love federalism, at least in theory. Democrats could offer to let states experiment with greater flexibility in how they run Medicaid (with some protections for the most vulnerable populations) in exchange for equivalent leeway for states that might want to combine federal and state health-care money to set up a single-payer system.
Given GOP voting strength among older voters, an idea that got shot down by Democratic senator Joe Lieberman during consideration of the original Affordable Care Act could make a comeback: allowing people nearing retirement age to buy into Medicare coverage. For progressives, this is a logical first step toward “Medicare for all.” For conservatives, it’s a fiscally responsible way to accommodate people who will never get affordable coverage in the private sector without big public subsidies.
The appetite of Republicans for any bipartisan approach will obviously vary in intensity, depending on what the party can accomplish on its own, and on which potentially baleful developments wherein the GOP needs bipartisan cover. Democrats should be especially vigilant about provisions that carry on Trumpcare’s malevolent intentions. For instance, it is almost certain that Trumpcare’s long-range Medicaid cuts will pop back up again in GOP budget legislation. In that case, Democrats might refuse to cooperate on bipartisan health-care legislation until Republicans agree to leave Medicaid — or for that matter, Medicare — alone for the time being.
But the donkey should wake up right away and weigh its options, even if it decides to bray and kick and refuse to go along with anything Republicans propose or are willing to accept. The GOP is in deep trouble right now, and terrified of ending the year with no real accomplishments despite its control of both ends of Pennsylvania Avenue. Democrats should be willing to exploit that vulnerability, if only to hand their opponents an anvil and encourage them to walk off the nearest cliff.