What if Republicans had compromised with President Obama in 2009? What would America's health-care system look like today?
We'll never know, of course. And certainly, some Republicans will argue there was no deal to be had with the Obamacrats that didn't involve lots more "big government," bloated spending, and unnecessary over-regulation. Indeed, some Republicans apparently still view health-care reform as purely an exercise in government shrinkage. As the libertarian Sen. Rand Paul recently wrote, "What should we replace ObamaCare with? Perhaps we should try freedom."
But freedom isn't free. And neither is universal health insurance coverage.
That's the pickle for Republicans. Guaranteeing universal coverage — or even maintaining current levels of coverage — while reducing spending is going to bedevil Republicans as they try to make good on their oft-repeated promise to "repeal and replace" the Affordable Care Act with, as President-elect Donald Trump puts it, "something terrific."
The GOP's long war to delegitimize and eventually dismantle ObamaCare has resulted in a catastrophic success. They won! But now the party lacks a clear, shared vision of what comes next. As a result, the congressional leadership's "repeal and delay" strategy — symbolically killing the law now while actually replacing bits and pieces over time — is generating growing resistance among rank-and-file House and Senate Republicans, including the influential House Freedom Caucus and Sen. Paul. Voters also seem reluctant, with 61 percent saying ObamaCare "should not be repealed until there is a new plan for replacing the law," according to a new Politico/Morning Consult poll.
It's hard to argue against such skepticism of "repeal and delay," an ill-conceived strategy plagued by multiple potential problems, as my American Enterprise Institute colleagues Joseph Antos and James Capretta recently outlined in Health Affairs.
First, it would "further destabilize an already unstable insurance marketplace" by nudging more insurers to drop out.
Second, stabilizing the marketplace until the GOP finally cooks up and passes a replacement is also problematic. Republicans have long decried many of the temporary fixes needed, such as maintaining the individual mandate and insurance company subsidies.
Third, the politics worsen as time passes. For instance, even though a replacement plan might spend less than ObamaCare over a decade, passing it after repeal would actually be scored as a spending increase of a few hundred billion dollars. Paul probably isn't voting for that. And cutting Medicare and Medicaid to pay for TrumpCare is probably out of the question since Team Trump seems keen on sticking to his campaign pledge to leave entitlements untouched.
Moreover, Trump himself doesn't seem to think much of "repeal and delay," tweeting a warning to his congressional allies to "be careful" that they don't get blamed for further ObamaCare troubles and advising them to work with Democrats to "come up with a healthcare plan that really works — much less expensive & FAR BETTER!" It seems that Trump wants an immediate repeal followed quickly by replacement.
So what should Republicans do?
The most obvious compromise is to fix and stabilize ObamaCare — such as deregulating the insurance exchanges — not repeal and replace it with something brand new.
But that's just a start. Republicans should go even farther than reforming ObamaCare. They should expand it.
Imagine an America where ObamaCare was so robust, where the exchanges were such a crackling hotbed of free-market activity and competition, that everyone purchased insurance this way, and no longer counted on their employers (or the government) for health coverage.
Many health policy analysts would love to "transcend ObamaCare" by, in effect, creating an ObamaCare-for-all (or TrumpCare-for-all) system that eventually moves everyone to individual health insurance policies sold through reformed ObamaCare exchanges. The result would be a more coherent, unified system where all Americans would get their health care through the private sector, with poorer Americans receiving refundable tax credits to purchase plans. It could make American health care more market- and consumer-driven overall — pleasing freedom-loving Republicans — while building upon President Obama's great achievement — pleasing Obama-loving Democrats.
It also seems like a more logical next step for the American health-care system, rather than to whipsaw it by undoing a nearly decade-old systemic reform with another systemic reform that repeals and replaces the first one.
And when you think about it, something like this really should have been first step all the way back in 2009. Maybe it's not too late to see what that compromise would have looked like, after all.