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Democrats should write their own “terrific” Obamacare replacement

Progressive ideas are lying on the table; it’s time to repackage them.

Constituents Rally Outside Senator Pat Toomey's Office, Demanding 'Don't Take Away My Health Care' To GOP Photo by Lisa Lake/Getty Images for Moveon.org

Donald Trump promised Americans “something terrific” in place of Obamacare, but it’s simply not possible to replace it with something that’s better for most people unless you violate the core tenets of conservative ideology. At times on the campaign trail, Trump suggested that he was, in fact, prepared to violate core tenets of conservative ideology. That’s one thing some of the voters who picked him liked about him. And while he’s done little since Election Day to suggest that he intends to follow through on that promise, there’s no reason Democrats can’t do it for him.

Nobody in the party believed the 2010 law was the last word on health reform, and nobody in the party needs to be constrained by the core tenets of conservative ideology.

By stitching together bits and pieces of Trump’s rhetoric with various improvement proposals offered over the years by the Obama administration and the Clinton campaign, Democrats can and should devise an affordable replacement scheme that moves the country closer to the single-payer system they mostly agree would be theoretically superior.

The ACA is good, but it could be better

The core reason to do this is that while Republicans have utterly failed to come up with a plan that actually improved on the problems they’ve identified with the Affordable Care Act, the problems themselves are real enough.

Here is Mitch McConnell, speaking to CBS on Sunday, describing the problems with the status quo:

Well, what you need to understand is that there are 25 million Americans who aren’t covered now. If the idea behind Obamacare was to get everyone covered, that’s one of the many failures, in addition to premiums going up, copayments going up, deductibles going up. And many Americans who actually did get insurance when they did not have it before have really bad insurance that they have to pay for, and the deductibles are so high that it’s really not worth much to them. So it is chaotic. The status quo is simply unacceptable.

McConnell reiterated these complaints in a Monday op-ed, but as Ezra Klein writes, McConnell “refuses to say whether he will insist that any Republican replacement actually fix these problems.”

He refuses to say because the answer, of course, is no. The GOP commitment to tax cuts for business-friendly regulations and tax cuts for millionaires makes it impossible for them to deliver anything useful to the 99 percent.

But that doesn’t make the complaints wrong. There are some exchanges that feature robust competition, and they are working a lot better than the exchanges that lack it. Bringing more competition to those troubled low-competition exchanges would be valuable and important. So would doing more to keep premiums and deductibles in check. And while these things aren’t doable within the ideological framework of the modern American conservative movement, that simply goes to show that the ideological framework of the modern American conservative movement is cramped and ridiculous. So much so that the GOP’s own president-elect kept rejecting it in the middle of a Republican Party primary, only to later embrace unity to secure the support of GOP donors during the general election.

Trumpy principles for a progressive replacement

The key to forging a sound Democratic Party replacement for the Affordable Care Act is to start with the wise words of Donald Trump. Unfortunately, that means taking the health care plan he promised on his website and throwing it in the garbage. That plan would cause 21 million Americans to lose their health insurance while depriving tens of millions more of critical regulatory protections. That’s not “terrific.”

But when doing things he actually cares about, like tweeting or going on television, he espouses very different views.

Protecting Medicare and Medicaid means you can’t repeal two core elements of the Affordable Care Act. You can’t scrap the Medicaid expansion, and you can’t scrap the payment reforms to Medicare. You’re left then only to talk about the “core” Affordable Care Act marketplaces, marketplaces that are successfully delivering affordable care to millions but that are still short of enrollment and competition goals.

Trump is, obviously, not a detailed policy thinker. But in a September 2015 interview with 60 Minutes, he laid out some core principles (emphasis added):

TRUMP: I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.

SCOTT PELLEY: The uninsured person is going to be taken care of. How? How?

TRUMP: They’re going to be taken care of. I would make a deal with existing hospitals to take care of people. And, you know what, if this is probably —

PELLEY: Make a deal? Who pays for it?

TRUMP: — the government’s gonna pay for it. But we’re going to save so much money on the other side. But for the most it’s going to be a private plan, and people are going to be able to go out and negotiate great plans with lots of different competition, with lots of competitors, with great companies, and they can have their doctors, they can have plans, they can have everything.

Trump, in short, campaigned on the same basic principle as Bernie Sanders — health care needs to be a right rather than a privilege. But he didn’t go all the way to endorsing a Sanders-style single-payer system. Even earlier in the campaign, at an August 2015 debate, Trump observed that single-payer “works in Canada," and "it works incredibly well in Scotland,” and “it could have worked in a different age” in the United States. But it would be too disruptive to interfere with people’s current employer-based arrangements and try to shift everyone to a government-run system.

Fortunately, a sound middle ground is available.

  • The version of the public option included in the House Progressive Caucus budget would reduce federal health spending by $218 billion over 10 years, by taking advantage of Medicare’s greater bargaining power.
  • Clinton’s campaign outlined three proposals to reduce premiums and out-of-pocket costs that the RAND Corporation assessed would reduce the ranks of the uninsured by a further 10 million while “decreasing average spending by up to 33 percent for those with moderately low incomes.”
  • Clinton’s benefit enhancements would cost $90 million, a small fraction of the $218 billion the public option would save.
  • The additional $120 billion or so could simply be allocated to the Medicare Trust Fund, contributing to further extending its life.
  • Last, while there is considerable debate as to the practical impact of Trump’s proposal to eliminate the “lines between the states” and establish a unified federal market in health insurance plans, it seems like an idea worth trying. In the context of a Republican repeal-and-replace plan, eliminating the “lines” would be a de facto total deregulation of the insurance industry. But relying on the Affordable Care Act regulatory minimums while allowing insurers to operate in as many (or few) states as they like seems desirable.

You could, of course, also throw some other favorite progressive ideas into the mix, like a Medicare buy-in for people over the age of 55 (though a good public option should make this unnecessary), steps to speed the approval of generic drugs, or the use of more aggressive pharmaceutical price negotiating techniques by Medicare.

Call it whatever you like

These and other ideas are longstanding wish-list items that have been floating around in various corners of the Democratic Party. You could, in theory, bundle them up with something technocratically sound but unpopular like a stronger individual mandate, or you could throw in something business-friendly like relaxing the employer mandate. Replacing the “Cadillac Tax” on expensive health insurance premiums (a policy labor unions hate) with a 28 percent cap on the deductibility of health insurance would probably also make sense here.

But the great thing about all these ideas is that they’re consistent with both longstanding Democratic ideas and popular things Donald Trump said on the campaign trail.

Democrats can characterize them as Affordable Care Act “fixes” or “tweaks” or “improvements” if they want to. Or they can call it an “alternative” or “replacement” to the ACA if that sounds better. Heck, they can even call it “Trumpcare.”

The important thing is that devising a plan would make two points. On the one hand, it would show that Democrats are not indifferent to the fact that the ACA has not been roses and unicorns for everyone. On the other hand, it would show that Obama’s challenge to the GOP to show him something demonstrably better for patients is honestly not that hard a standard to meet.

Republicans can’t do it not because they’re stupid or because it’s conceptually impossible. They can’t do it because they are ideologically rigid and obsessed with cutting taxes and deregulating business. Trump himself will then be challenged to either demonstrate continued fealty to his adoptive political party’s narrow ideology or deliver on his campaign pledge to show flexibility and deliver something “terrific.” Either way, it’ll be a win.

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