Both the House and Senate bills are, at their core, naked attempts to get a majority for something that can be called a repeal of Obamacare, not expressions of philosophy about the delivery of health care in the US. The question for today is, if you could divorce the need to “win” from the equation, what would a GOP health care bill say? The wide range of answers explains why it is so difficult for the GOP to agree on a single piece of legislation.
Here are the options, as I see them:
1. Repeal Obamacare, and return to the status quo ante: This would be relatively simple from a technical perspective, and would have strong support from the base. Advantages, from the GOP’s point of view: completely eliminates a new entitlement program enjoyed largely by the undeserving poor; sends a message that health care should be treated like any other commodity in the market. Disadvantages: Probably deprives about 30 million people, many of them GOP voters, of health insurance; health care providers (often GOP voters) lose big bucks; countless job losses in the health care field; individual insurance markets may go into a death spiral. Overall assessment: CLs and some Reactionaries support this approach, but no one else does, because the down sides far outweigh the advantages.
2. Maintain most of Obamacare’s architecture, but replace community rating with high risk pools: This is contemplated in the House bill. Advantages: lowers premiums for young and healthy people; moves the focus of health care back to personal responsibility. Disadvantages: if (this is unlikely) the high risk pools are adequately funded, the GOP is maintaining a very expensive entitlement program; if not, GOP voters with pre-existing conditions will be turned into unsuccessful beggars. Overall assessment: unlike the poor, prosperous GOP voters with pre-existing conditions are sacred cows. There is nothing in the history of high risk pools which suggests that the funding would be in any way adequate to the task.
3. Create a system of universal catastrophic insurance: The Senate bill moves tentatively in this direction. A somewhat workable system would include prefunded HSAs for the poor, tax advantages for HSAs for everyone else, and tax credits adequate for the purchase of high deductible plans for all. Advantages: this approach essentially eliminates the use of insurance for daily care, which, in the eyes of the GOP, will reduce waste and ultimately cut unit prices. Disadvantages: keeps an expensive entitlement program in place; will have a very limited impact on pricing. Overall assessment: there is some merit to this approach, but without substantial government intervention to drive down prices, as in Singapore, it won’t work.
Both philosophically and practically, there are very large differences among these three concepts. That is why getting 50 votes is so difficult, even for a magician like McConnell.