Washington • Wanna know the reason Republicans have had so much trouble coming up with a “replacement” plan for Obamacare?
Because if Republicans actually tried to devise a health care system that fulfilled both conservative principles and their public promises, they'd probably propose something that looks too much like … Obamacare.
For reasons few can fathom, President Trump has revived the GOP’s disastrous, nearly decade-long effort to destroy the Affordable Care Act. In a legal brief filed Monday, his administration told a federal court that it believes the entirety of the 2010 law should be declared unconstitutional — not just the now-neutralized individual mandate but also all the popular stuff, too, including protections for those with pre-existing conditions, letting young adults stay on their parents’ insurance until age 26, individual-market subsidies, Medicaid expansion and so on.
Trump's own health and human services secretary and attorney general reportedly opposed the move, as did Republican congressional leaders.
They must recognize that past Republican threats to health care coverage helped power Democrats' wave election in 2018. And they likely foresaw that attacking the ACA would unify the left — which had become divided over single-payer — even as it divided the right on what the heck to replace the repealed law with.
Nonetheless, Trump boldly proclaimed the GOP the "party of health care" and subsequently instructed Republican lawmakers to come up with "a plan that is far better than Obamacare." Or to use his earlier coinage, "something terrific," though Republicans have had nearly a decade to produce that something and failed to deliver.
In fairness, it's a near-impossible task, assuming terrific-ness requires (a) adhering to Republican principles; (b) fulfilling Trump's promises to protect those with pre-existing conditions and guarantee "everybody" gets covered; and (c) not producing a near-facsimile of Obamacare.
Despite the constant accusations of socialism, after all, the basic framework of the ACA uses market-based mechanisms to expand coverage and keep cost growth down. It preserves the private insurance industry, which is still the largest provider of insurance, and relies on private hospitals and providers. It was based on a plan first implemented by a Republican governor who went on to become the 2012 Republican presidential nominee: Mitt Romney.
One of the three legs of Obamacare's "three-legged stool" — the individual mandate for people to carry health insurance — was also featured in a health reform proposal once promoted by the conservative Heritage Foundation.
Trump and his co-partisans have now explicitly committed to protecting another of those "legs" — preventing insurers from denying coverage or raising premiums for those with pre-existing conditions — at least in rhetoric, though not in practice.
To be sure, there are parts of the law that Republican officials are less keen on, including subsidies to make insurance more affordable (that third "leg") and the Medicaid expansion. But these are now quite popular, too, even among Republican voters, according to polling from the Kaiser Family Foundation. So good luck killing them.
The ACA is by no means a perfect law. It did a lot to expand insurance coverage but not enough to reduce costs. As written, it was too vulnerable to sabotage from those with political motive to do so. Republicans could have spent the past decade working with Democrats to make the law stronger; instead, they worked to destabilize markets by abruptly changing the rules on insurers and cutting funding for implementation of the law.
Besides subtracting elements of the ACA, Republican officials have also made some additions to the U.S. health care system that have not exactly proved successful.
In fact, Trump’s administrative efforts to add work requirements to Medicaid were blocked by a federal judge Wednesday — specifically because, the judge determined, the programs in question (in Kentucky and Arkansas) did not advance Medicaid’s basic purpose of providing health coverage. The Big Government bureaucracy necessary to correctly ferret out the tiny population of supposedly “undeserving” Medicaid beneficiaries targeted by such programs is also arguably not terribly conservative; if promoting work was the objective, there are much more effective ways to do so than ripping away access to health care, which often enables people to work.
In any case, Republicans have demagogued themselves into a corner, and they know it. The late Republican senator John McCain arguably saved the party from itself by killing the last legislative attempt at "repeal and replace"; now that Trump has foolishly revived this losing battle, Republicans will be forced to return to shouting "Free markets!" into the wind, as though that will somehow produce a real policy.
Catherine Rampell
Catherine Rampell’s email address is crampell@washpost.com. Follow her on Twitter, @crampell.