As Republicans struggle to come up with a repeal and replace plan for the Affordable Care Act, Democrats are indirectly presented with an interesting question: what would ending the fight over health care be worth to them?
So far Democrats are just sitting back and hoping congressional Republicans fail. This would technically leave the ACA in place, but this strategy is a major policy and political gamble. Even if this strategy succeeds, it means having the management of the ACA -- which has so far depended on aggressive/legally questionable regulatory maneuvering by the Obama administration to keep it semi-functional -- will be in the hands of a very resentful administration for the next four years. President Trump has already said he thinks the politically easiest thing to do would be to let Obamacare “implode” on its own in the next few years rather than push for a replacement.
If the Trump team decides to undermine the ACA over the next four years, Democrats might be able to successfully get voters to blame this “failure” on Trump, but it is hard to know how the optics would play out with Republicans blaming the law instead. Most voters don’t understand the complexity of properly running things like reinsurance programs to truly judge who is right in such a technical dispute. The ACA has gotten more popular during talk of repeal, but its approval numbers are still very weak.
For now just watching as Republicans flounder is a good strategy, but if Democrats decide to throw Trump a political lifeline at the last minute, they have four big things to gain.
1) GOP accepts principle of everyone getting help: Based on President Trump’s recent statements and the leaked draft proposal from House Republicans, the GOP leadership is prepared to officially make two big ideological concessions: that no one should be denied coverage because of a pre-existing condition and that every American regardless of age, sex, or income should get help from the government affording health care. As a matter of principle, that is not something even we saw from the ACA, which left many middle class workers with no help and no affordable coverage. This is why the Freedom Caucus is so upset -- they know what a big paradigm shift this new entitlement would be. While far from perfect, the current GOP ideals would end the partisan argument about whether the government should help everyone get coverage and change the fight to how/how much help.
2) Trump buy-in to try to make it work: Don’t underestimate how much leeway the executive branch has to make laws work or not. A worse law that the executive branch is really trying to make work could easily perform better than any law the administration is trying to undermine.
3) Red state buy-in for Medicaid: Any bipartisan replacement law will likely have a worse version of the Medicaid expansion. However, if it gets the blessing of Trump and Paul Ryan, you can bet that all the red states will take part. That adds up to some 2.5 million people who could benefit.
4) A chance to fix some of the ACA’s problems: The ACA has some real problems that range from big to small technical issues. This would be a chance to fix some of them. If Democrats don’t get a GOP buy-in for fixes now, it could be -- what, four years? eight years? 12 years? -- before they regain full control of Washington to approve any fixes.
So the question for Democrats is what is all of this worth to them? How much better does the draft GOP plan need to be? If the Republicans agreed to, for example, peg the age-based tax credits at the cost of a catastrophic plan and leave Medicaid expansion mostly alone, would that make ending the fight worth it? I don’t have the answer and the opportunity may never come up, but it is a question that the party should at least quietly be thinking about.