Seven years ago, the Democratic Party found itself at a crossroads. Its sweeping health care bill was increasingly unpopular — the subject of angry town hall protests, the cause of a shocking special-election defeat in Massachusetts. Some people in the Obama White House wanted to scale back the bill, to drop the idea of reinventing the individual insurance market and simply expand Medicaid.
Instead, the Democrats chose to stick with Obamacare, which earned them a historic achievement — and then a cataclysmic midterm defeat from which their fortunes as a national party have never quite recovered.
Now it is the Republican Party’s turn to face a health care choice. They can forge ahead with the “repeal” of Obamacare, notwithstanding the massive unpopularity of the legislation being negotiated in the Senate, on the theory that they’re more insulated than the Democrats were in 2010 and that the policy achievement is worth the political pain. Or they take the road the Democrats did not and retreat to a much smaller bill instead.
The case for retreat is stronger than it was for Barack Obama’s party. The Democrats in 2010 were on the cusp of achieving their decades-old health care policy dream; the Republicans in 2017 can’t agree on what their health care policy goal should be. In order to mitigate its unpopularity, Senate Republicans keep making their bill more like, well, Obamacare, which raises the question of why they’re attempting something so complex for such a modest end.
But what would retreat look like? Don’t worry, I have the answer. First, the smaller bill would repeal the individual mandate requiring the purchase of insurance. It would replace it, as the Senate bill does, with a continuous-coverage requirement — a waiting period to purchase insurance if you go without it for more than two months.
Second, the bill would repeal some of the taxes on health care spending, saving and services imposed by Obamacare, including the taxes on medical devices and prescription medications, the higher threshold for deducting spending on chronic care, and the limits on contributions to health spending accounts.
Third, the bill would maintain the stabilization funds that the Senate legislation pays to states and insurers to help cover the sickest Americans and keep exchange prices from spiraling upward.
It would impose a per-capita cap on future Medicaid spending, but a less draconian one than the current legislation envisions. Instead of wringing almost $800 billion out of Medicaid over 10 years, it would try to reduce the program’s spending by $250 billion.
That’s it. That’s the whole thing. Eliminate the hated mandate, keep the exchanges stable, cut a few health care taxes and pull Medicaid spending downward. Pass the package, declare victory, and pivot to tax reform.
All of this would be tepid and incrementalist. But the Republican Party is too divided on health care, too incompetently “led” by its president, and too confused about the details of health policy to do something that’s big and sweeping and also smart and decent and defensible.
So if the party insists on doing something, it should do something appropriately timid. The alternative is a big gamble on a bad bill — not just a crime, but a mistake.