The well-intentioned call recently by U.S. Sen. John McCain, R-Arizona, for Republicans and Democrats to put aside political divisions and return to what is called “regular order” to work out a compromise between the Affordable Care Act and the Republican call to “repeal and replace” the ACA is unlikely to succeed.
The philosophical divide between core groups within each party is irreconcilable.
Core Republicans want a largely free-market approach to health care, where patients, doctors, hospitals, and insurance, pharmaceutical and medical appliance companies are all competing in the marketplace in a manner that best meets their needs. It’s Adam Smith’s “invisible hand” applied to health care, and they are prepared to tolerate 50 million uninsured people.
That’s what we had before the ACA.
Core Democrats see health care not as a constitutional right (it’s clearly not), but as a type of human “right.” They want a more regulated health care system, where patients, doctors, hospitals, etc., have considerable – but not unfettered – choice. They are not prepared to tolerate 50 million uninsured. They saw an imperfect ACA as a step in the right direction, where 20 million more people had meaningful health-care coverage.
The philosophical divide is so entrenched that Democrats could not get a single measure that improved, streamlined, or removed flaws in the ACA through a Republican Congress in the seven years since the ACA’s passage.
The Republicans, with seven years to think about how to bridge the philosophical divide, couldn’t do it. They control the Oval Office and Congress, but could not legislate “repeal and replace.” Every Democrat held firm, and a small group of Republicans (who would not allow millions to again be uninsured) defected.
That’s how even the philosophical divide is.
At this point Republicans cannot stop; they made promises to their constituents. Grudgingly for many, they will return to “regular order” to fashion (with “blue dog” Democrats) what will be called a compromise. The worst of total ACA “repeal” will be avoided. Perhaps 8 million-12 million of the newly insured will be able to retain some form of coverage.
The total number of uninsured may well drop to 38 million-40 million. Minor repairs to the ACA focused on the elderly, those with pre-existing conditions, the current opioid crisis will be made. Almost certainly, large parts of ACA’s Medicaid expansion (utilized by 31 states) will be turned over to the states with few, if any, strings and generous (up to 90 percent) federal financial support.
When (if) this “regular order” legislation passes, Republicans will claim victory and “promises kept.” Democrats, too (but in a more muted voice), will claim victory, because the worst will have been avoided and a more bipartisan approach to serious issues will have been re-established.
But with respect to larger health-care issues, the core in each party will know and feel that they have lost. More importantly, neither party will give up.
Republicans, in the name of deficit reduction, will begin calling for overall cuts to Medicaid. They are unlikely to press hard on insurers or the pharmaceutical industry; in little ways they will cut useful health care regulations. If costs and the number of uninsured rise, so be it.
Core Democrats see the 2018 elections as critical. They need to regain at least one branch of Congress; they will tout the fact that millions who were insured under the ACA, and nearly 40 million overall, have no health insurance; that many of these people are deserving poor; that our free-market health-care costs are double that of any other country and produce woeful health-care outcomes (people are dying needlessly).
In other words, the philosophical divide will not go away.
Republicans (subtly or less so) will talk about the “lazy” poor; the bogeyman of “socialized” medicine; “death squads;” the right of all Americans to choose their own doctor, health care, etc., which falsely assumes they have the resources to make any choice at all.
Democrats will talk about greed within the health care industry; human dignity – particularly that of innocent children, elderly, and handicapped individuals; preventive medicine, and that insurance for all will, in fact, reduce the nation’s health care costs.
In short, this philosophical divide seems intractable. Given that facts count for so little, it will sadly not be bridged any time soon.
Orlando Delogu of Portland is emeritus professor of law at the University of Maine School of Law and a longtime public policy consultant to federal, state, and local government agencies and officials. He can be reached at firstname.lastname@example.org.