With the 115th Congress already underway and inauguration just over a week away, lines are being drawn for a fierce, partisan health care battle. It doesn’t have to be that way. With two relatively straightforward acknowledgements, Republicans could create a pathway for bipartisan reconsideration of health care coverage in America.
Take Medicare Off the Table
Republicans have expressed interest in repealing and replacing the Affordable Care Act (ACA), restructuring Medicare to a premium support model, and reforming Medicaid through either block grants or per capita caps. Taking on all three programs is an extremely heavy lift — both politically and legislatively. If it is improbable to do all three, Republicans should openly acknowledge that they are taking Medicare restructuring off the table. This is not meant to belittle the importance of Medicare as a fiscal issue. The reality is that this election was in no way a mandate for major Medicare restructuring, and the President-elect came out rather strongly against the concept during the campaign.
With premium support-style Medicare reform off the table, the political calculus changes dramatically for the Democrats. The Democrats have been revving up the Medicare privatization rhetoric that has been politically beneficial since 1995. Without Medicare as a rallying point, Democrats would be forced to defend the Affordable Care Act (ACA) which is relatively unpopular and in need of reconsideration. Refusing to engage might not be in their political interest. And while the Medicaid program is critical to the people it serves, it has not been shown to be the salient political issue that drives voters the way Medicare has.
If Republicans can take that first step by publicly acknowledging they will not pursue Medicare reform, they then need to follow by further acknowledging that an ACA replacement bill that costs 10 million or more Americans their coverage cannot become law. Democrats and Republicans should not hold themselves to specific targets given the imprecise nature of estimating. The 2009 estimates of the ACA have proven to be wrong by nearly half. That said, there are policy choices that can be shown objectively to cost 10 million people or more their coverage. The Democrats would walk away from any conversation around those policy choices to be sure, but it’s not clear that there’s consensus among Republicans to cause 10 million Americans to lose coverage. And again, it’s far from clear that the President-elect would sign a bill that cost 10 million Americans their coverage. If Republicans make clear that covering people is more important than kicking people off coverage, Democrats should want to be at the table.
Lessons from the Medicare Modernization Act
Republicans should remember health care history. In 2003, while in control of the White House and both chambers of Congress, Republicans were willing to jettison covering prescription drugs in Medicare only through what became Medicare Advantage in order to kickstart bipartisan negotiations. The resulting bipartisan bill, the Medicare Modernization Act that created the Medicare Part D prescription drug benefit for seniors, was substantially what Republicans sought and Part D remains quite successful and popular today. In 2009, while in control of the White House and both chambers of Congress, the Democrats refused to step back from the public option that would have created a government-run insurance plan to compete with private insurers, even though its ultimate inclusion was always improbable, jeopardizing the frail efforts at bipartisanship. Republicans face a similar decision. Republicans can cling to the improbable or acknowledge their willingness to concede now to achieve bipartisan consensus. Bipartisan consensus in health care would be a remarkable achievement for Congress and a remarkable victory for the people they serve.