Some conservative policy pundits are starting to imagine a detente over Obamacare, in which Republicans recognize the conservative nature of the law and support it in return for tweaks that advance their ideas. Liberals should be open to such a deal.
Even though Democrats passed it, the Affordable Care Act offers a hospitable environment for conservative reform. That’s not just because it incorporates aspects of a proposal from the conservative Heritage Foundation, closely resembles the health-care-reform bill that Mitt Romney signed in Massachusetts, and bears striking similarities to earlier proposals by Republican members of Congress. No, the reason the ACA may be good for conservatives is that it provides a sound chassis for many of their health-policy proposals.
Some of us have been saying so for years; finally, some conservative thinkers are recognizing it too. In a recent op-ed, Paul Howard and Yevgeniy Feyman offer ideas that would “make Obamacare a Trojan horse for conservative health-care reform.” Ramesh Ponnuru, Yuval Levin and Ross Douthat have also proposed reforms consistent with Obamacare’s structure. Well, it’s about time! Despite that the ideas are being offered from the right, liberals should rejoice.
Imagine what could be accomplished if conservatives built a coalition for reasonable changes to the law, instead of wishfully thinking repeal was within reach: Democrats could rest easier about the law’s future, and Republicans could advance their priorities. With the basic structure in place, so much could be achieved with relatively modest change.
Some conservative ideas mesh seamlessly with the ACA’s structure. It would, for example, be easy to change the law so that more catastrophic plans could be offered on exchanges. Similarly, adjustments to the “Cadillac tax” on high-cost insurance plans could help to cap or phase out the employer-sponsored health insurance tax subsidy, a goal that House Budget Chairman Paul Ryan has supported. Finally, the exchanges could be adjusted to permit health insurers to offer coverage across state lines. Starting in 2016, states are permitted to voluntarily enter compacts for that purpose; the law could be changed to allow even more of it.
To be sure, liberals will resist such rightward moves, which may look like steps away from the left-wing ideal of a single-payer, “Medicare for all” system. But the law isn’t built to advance such a system, and Democrats might as well accept it. In fact, they may as well embrace the law’s conservative design too, and invite Republicans to take advantage of it. In exchange, they should negotiate some much needed fixes to the law. Three come immediately to mind:
First, resolving what’s known as the family glitch, in which some families simultaneously face unaffordable health insurance options at work and are ineligible for exchange-based premium credits. Second, making sure cost-sharing subsidies are not subject to government cuts known as sequestration, the consequences of which are uncertain. Third, clarifying the language of the law to remove any suggestion that premium credits be provided only through state exchanges, not the federally operated exchange that 27 states rely on.
There’s nothing wrong with this kind of trade. After all, big laws need occasional tweaks to survive in the long run. More important, bipartisan give-and-take on health policy, undertaken in good faith, has the potential to solidify liberal ends. Bringing Republicans into the reform tent would make them responsible for trying to hold it up, stabilizing health-care politics and cementing a broader, bipartisan coalition for near-universal coverage. That would be a victory for Democrats.
If there’s an obstacle here, it’s politics. Good ideas and reasonable compromises give way all too easily to the opportunity to demagogue or the need to appeal to the base. That gap can be bridged by arduous coalition-building -- something Democrats did to pass Obamacare but hasn’t occurred in the name of a more conservative health policy agenda. And it won’t happen until conservatives stop encouraging, and elected Republicans stop taking, repeal votes.
Neither Democrats nor Republicans got everything they wanted in Obamacare, but Republicans, without casting a single vote for it, achieved more than they’re willing to admit. It’s long past time for them to accept the law as a working template for the future, and for both parties to reach reasonable compromises to improve it.
(Austin Frakt is a health economist with the U.S. Department of Veterans Affairs.)
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