Editor’s Note: Below, Len Nichols, Professor of Health Policy and Director of the Center for Health Policy Research and Ethics at George Mason University, discusses President Obama’s State of the Union address and House Budget Committee chairman Paul Ryan’s (R-WI) Republican response. See other posts on this topic by Kavita Patel and Joseph Antos. 

In last night’s State of the Union address, the President offered, once again, to listen to Republican ideas that can improve the Patient Protection and Affordable Care Act, like malpractice reform.  But he said, rightly, that he is not willing to scrap the law and start over.  He is not willing to return to the status quo in which insurers can profit by underwriting Americans with health conditions out of access to care and to life.

Representative Paul Ryan, in his response, said once again that first we must repeal our promise to enable all Americans to access high quality insurance and care, and then Republicans will propose ways “to reduce cost and expand coverage.” 

To probe this fundamental disagreement to a place nearer clarity, let’s state some facts.   Republicans in Washington, since President Obama was elected anyway, have been unwilling to agree to or even consider any proposal that will cover all Americans.  In fact, the so-called “Boehner alternative” to the PPACA — based as it was on deregulating private insurance, modest tax credits, and no delivery system reform at all — would cover less than 10 percent of the uninsured. 

The biggest chasm between these competing visions of a better health care system is this: Democrats are for making sure all Americans can sit at our health care table of plenty, and are willing to change the rules and incentives so that insurers and providers will have a self-interest in enabling that happy outcome, and are willing — yes — to tax ourselves so the less fortunate can afford it. Republicans are for lower tax rates and less government, regardless of the health consequences for our citizens who cannot afford what those with market power want to charge. 

Republicans apparently do not think that the lack of coverage of tens of millions Americans, nor the unsustainable health care cost growth that is really killing jobs, are worthy of serious collective effort.  I wish they would just say that, or that Democrats were more skilled in making them admit it, to clarify the issues before American voters.  Instead, Republicans seem content to just take cheap shots at Congressional Budget analysts for scoring bills honestly, and to invent false claims like death panels, job killing, budget busting, etc.  They are outstandingly successful with campaign sound bites, I do admit.

Paul Ryan’s Roadmap Versus Earlier GOP Proposals 

Now Paul Ryan at least is honest in his Roadmap (though I note neither Boehner nor his colleagues have endorsed it).  His plan for long run health care cost growth control?  Convert Medicare into a fixed growth rate voucher program, where the voucher is set at a value at roughly two-thirds of today’s benefit package, while Medicaid will become a block grant that also shifts all risks to states and patients.  And Ryan hopes the delivery system will magically adjust.  But at least he’s honest about it.  He just ignores the potential of incentive realignment and delivery reform to help us achieve fiscal sanity more humanely.  For that would require government to take action.  And that is ideologically impermissible, since active government is always and everywhere bad, or so they say, every day in the well of the people’s House.

I am old enough to remember when real Republicans actually proposed credible alternatives to Democratic plans to improve our health care system (admittedly, before the Tea Party and other conservatives declared war on moderates in both parties).  In 1993, 14 Republican senators joined World War II veterans John Chafee of Rhode Island and Bob Dole of Kansas and supported a proposal that centered on insurance reforms, new market places for small groups and individuals, and an individual mandate; it covered all Americans and paid for it all through reducing the open-ended tax subsidy of high income Americans that our current tax policy permits, and with Medicare savings. 

Does this sound familiar?  Yes my friends, “Obamacare” was a Republican idea before it became “socialism” in the distorted mirror of the last two years.  By the way, two of the co-sponsors of that Chafee-Dole alternative to the Clinton plan were named Hatch and Grassley.

Is There A Way Forward?

So what is to be done?  There is much to improve in PPACA, and some of those better ideas are still “Republican,” such as malpractice reform; more state flexibility to reorganize Medicaid and the problematic small group and individual insurance markets; and a budget failsafe device linking coverage expansion subsidies to realized delivery reform savings.  Even selling insurance “across state lines” would be a good thing if there was a national floor on insurance market regulation, as PPACA would institute.  Maybe the (mostly) sensible and pragmatic governors can cut their own deals with the Obama administration and amend PPACA sensibly through regulations and waivers.  But a productive national debate will return only if we agree on the facts that 50 million uninsured is a moral disgrace and that health care cost growth cannot be tamed by parsimonious benefit packages alone. 

In short, Democrats and Republicans could work together like 60-65 percent of Americans actually want and need them to, IF Republicans will admit that the Democrats have defined our health care problems and need for urgency more accurately, and IF Democrats will admit that Republicans have some good ideas about making markets work better and about preventing fiscal liabilities from overwhelming us.   Given their disingenuous behavior of the last 2 years, I think Republicans should have to offer candor and honesty first, but if both parties can announce it publicly together, that would always be optimal. 

Of course this is unlikely to happen, frankly, unless and until independent voters punish them (again) for policy prescriptions so divergent from the reality and urgency of our situation.  The political debate over defining that reality may largely determine the 2012 election and the one after that.  I intend to spend more time in the next few years learning about our health care system’s potential for reforming itself at the state and local level and less time waiting for a brave and honest Republican to stand up in Washington.  Godot isn’t coming until 2013.  At the earliest.