Republican Trudge toward Suicide

Republicans damned if they do.  Damned if they don't.

Solution:  Do as little as possible and put the blame on someone else.  

Health care in America is simple.  The politics of health care is not.   If America had Medicare for everyone, and added a 5% surcharge to all incomes from every source, we could have Medicare for all.   It would be pretty simple, universal, good, and it would be less expensive than what we have now.  It would largely remove the insurance industry cut from the health care cost structure, which would save money.

There would be complications.  Medicare insurance reimbursements aren't enough in some areas (like Oregon) but they are higher in other areas for the same procedures (like NY and Florida) so there needs to be some adjustments.   It would lower cost for employers since health care would quit being an "employer" expense and it would become a citizen expense paid in higher taxes.  Again, there would need to be adjustments and presumably people would be paid more in wages (to cover the tax) to replace the health care cost currently buried in the personnel cost under contained under "benefits."    There would be transition hassles, and some people would be hurt, including health insurers, who would scream.

Why not do it?  It would be a form of wealth distribution because rich people would pay in taxes more than the costs of their own care and poor people would get the extra help because their healthcare is more expensive than the taxes they pay.   The rich don't want to subsidize the poor.   Even middle class people who feel they personally "have a good deal", either because they are on Medicare or because they have a secure job with benefits do not want to pay for the health care of others less fortunate.   Even though the current system is inefficient and incomplete and wasteful, there are relative "winners" and those winners don't want equality.  They want to hang onto a sweet deal.  The many winners in the current system are politically powerful--seniors who vote, people with good jobs, the wealthy who write campaign donation checks.

Bashing the ACA was great politics.

The ACA--Obamacare--put bandaids onto a flawed system and made it somewhat more universal.  Republicans prospered by complaining about what it cost and what it did not do.  They promised "repeal" and voted some 50 times in the House to show their resolve.  

They won the House, Senate, and White House in large part by bashing the ACA.  That is the problem.  Now they have no excuse for being the party of mere critics rather than the party that solves problems.

Some Republican congressmen--especially those in the Freedom Caucus--oppose the subsidies for insurance and expanded Medicaid, so they oppose the ACA on the issue of thrift and morality: let the uninsured poor make better life choices so they would have the money they need for cancer surgery.  Some Democratic activists think this is terrible politics for Republicans--the working poor being thrown off a lifeboat--but for many it is not.  Remember, there are more winners than losers in the current inefficient and spotty system.  The winners consider their place in the system well deserved and just and the current losers to be improvident.  "Why pay to support lazy people and welfare cheats?" There is a big caucus of Republicans who want less--the thrift caucus, and there are voters who like hearing them stand tall for the taxpayer.

There is another group of Republicans who want to continue health insurance for the working poor.  Those blue collar and working poor people vote Republican.  They were the group that voted for Trump.  They are a big part of the margin for red-state/red-district Senators and Congressmen.  (There are lots of them in my red-district Congressional district, almost 1/3 of the voters.)

Republican officeholders are stuck with their promise:  end Obamacare.  They look like failures when they did nothing on healthcare repeal, so they are going back to try again. (I personally think the smartest political strategy for Republicans is to accept failure because doing nothing keeps the attention of the problems with the ACA, but I apparently underestimated Trump's competitive drive and to be able to show a "win", even if the "win" on health care will transfer the albatross from Obama to the GOP.)   The GOP is moving forward. This time the new Republican bill will be more stingy.  It will be cheaper.  It might pass the House.

Its real purpose is to pass the buck.   A new House bill will pass the buck to the states.  States will get permission to use federal Medicaid money how they want, being told if they want to expand Medicaid to help more of the working poor they can pay for it.  A House member can defend it as "giving states the power" when it is actually saying, let the states take the blame for people not having affordable health care because, of course, there is little or no state money for this.   It also passes the buck to the Senate.   Senate districts are statewide and therefore almost alway include a broader mix of people than do House districts, especially carefully gerrymandered ones.   The Senate will not pass a stingy ACA replacement because there are too many people who would lose access to coverage, including people that Republican officeholders identify as sympathetic victims: older people and small business people and lifelong Republicans who have pre-existing conditions that mean that no insurance company would willingly cover them without a subsidy.   Any provision that allows coverage for pre-existing conditions dooms any new plan to complexity and compulsion.   (Otherwise it wouldn't be insurance.  People would simply wait until they have a problem, get "insurance" and someone else would help pay.)


The Republican suicide is their twin burdens, being forced to do what will hurt them when they do it.  If they do nothing on health care they are revealed as dishonest in the promise to repeal and unable to govern.   If they do something on health care the House will appear to be able to govern but they will push forward a bill that the Senate cannot pass.  House members can extoll the vague virtues of their bill safe in the knowledge that it will not pass so no one can look closely at its problems.   Senators get national attention.  They grandstand.  Republicans House members can blame ideological Senators and their ambitions.

House Republicans may be safe, but they would still injure the GOP brand.   The divisions in the Republican caucus would be visible: what pleases Susan Collins is hated by Rand Paul.

What if something actually passes the Senate?  Full disaster for Republicans.   

Trump would sign a law that will have critics and sympathetic victims from day one.   Millions of people would be pushed off the Medicaid expansion.  Fifty states would complain. Insurance subsidies would be reduced.  There would be millions of sympathetic victims clear that Trump and the GOP got their vote then stabbed them in the back.

The group of people hurt--the blue collar, working poor, red-state/red-district non-college voters who helped Trump win the electoral college are exactly the people who would be most hurt by a thrifty-GOP plan.   Democrats would have a huge messaging bonanza.  Their current problem is explaining that the ACA has problems because Republicans are intentionally starving it and disallowing the "insurance corridors" that would have allowed it to work as intended.  If there is Trumpcare then the branding is easy.

Healthcare in America--now and if there is a GOP Trumpcare--will not be universal, simple, inexpensive and good.   It will be spotty, complicated, expensive, and bad. 

Democrats will know whom to blame.  Republicans broke it and Republicans replaced it with a monster.