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Democrats Should Seriously Consider This GOP Alternative to Obamacare

It could save health care reform—or at least delay the repeal effort.

Bloomberg/Getty Images

Against a backdrop of increasing liberal concerns that Democrats in Congress are being too solicitous of President Donald Trump, too accommodating of his cabinet nominees, too concerned about the challenges they will face in the 2018 midterms, it is worth noting that Democrats have given Republicans no quarter in their efforts to abolish the Affordable Care Act. Democrats have insisted, too, that any alternative health care reform plan be just as expansive as Obamacare and provide people access to a similar level of care.

In that spirit, Senate Minority Leader Chuck Schumer was unsparing Monday in his critique of a rare proposal by two Republican senators that, unlike other GOP proposals, doesn’t call for undoing all of Obamacare’s progress and starting over.

“While I have a great deal of respect for senators [Susan] Collins and [Bill] Cassidy, their proposal today illustrates the dilemma both they and Republicans are in,” Schumer said. “Ultimately, this proposal is an empty facade that would create chaos—not care—for millions of Americans. Republicans should drop their disruptive repeal plans and work with Democrats to improve, not gut, the Affordable Care Act and healthcare system for all Americans.”

It would have been a negotiating failure had Schumer said anything less critical. Collins and Cassidy propose to let states choose whether they want to:

a) Keep Obamacare

b) Switch by default to a system in which the uninsured are automatically enrolled in a catastrophic health insurance plan and a subsidized health savings account

c) Opt out of the 2010 health insurance expansions entirely

They would fund this alteration by retaining the ACA’s tax increases and by transferring authorized federal spending on beneficiaries to the states (the amount in the proposal assumes 95 percent of eligible Obamacare beneficiaries were enrolled, which is much higher than the ACA has attained).

Because this would be disruptive, and leave poor and working-class people in states that opt out far worse off than they are today, Schumer was right to reject it.

But that doesn’t mean other Democrats shouldn’t treat it as an opening bid, and strike up conversations across the aisle to see if it can be improved. Backchannel bipartisan negotiations are how members of Congress either dither or make real breakthroughs. Either outcome would help Democrats achieve their ultimate goal: to stop Republicans from taking health insurance away from millions of people.

There are problems with the Cassidy-Collins approach and with the rapid effort to translate it into legislative language. Health law expert and ACA supporter Timothy Jost explores them at length here. The benefit structure is more regressive than the one the ACA created, for instance, and the language apparently makes it unclear whether the federal transfers would grow with medical inflation or simply leave beneficiaries paying more out of pocket every year until the whole thing becomes useless. But while Jost concludes the Cassidy-Collins bill “is not ready for enactment,” he notes it “may form a basis for discussion” and that, with respect to hypothetical efforts to replace Obamacare, Congress “could do much worse.”

There are many conservative health care reform ideas that are basically incompatible with a humane view of the federal government’s responsibility to improve public welfare. Most Republicans want to cut spending on the poor, completely deregulate health insurance for the working class, and insulate doctors from medical liability. What makes Cassidy-Collins worth consideration is that it doesn’t waste much time bothering with these nostrums. Or at least, they aren’t the cornerstones of the plan.

What it may offer is a basic tradeoff: cover more people, but with fewer guaranteed benefits. There are versions of this tradeoff, not yet embodied in this legislation, that liberals should happily consider.

Obamacare offers crappy-to-great insurance to the uninsured, but at costs that have made it prohibitive for millions of people. That means a great many people are benefitting, getting care, and have been let out from under the medical bankruptcy sword of Damocles. It also means about as many people are just as exposed as they were before.

It is easy enough to imagine an alternate Obamacare which automatically enrolled every single uninsured person in a single public plan that paid for treatment in the event of injury or major illness, and then subsidized supplementary coverage, so poor and working class people wouldn’t have to forego more routine care. The tradeoffs would be painful; comprehensive individual and family plans would change; some people would end up with worse coverage so that the poor and near poor could get any at all. But they would result in a truly universal benefit—one upon which future Congresses could build to benefit everyone.

This isn’t what Cassidy and Collins are proposing as their default plan, but it’s not so wildly far off that Democrats shouldn’t try to push it in that direction. If they make strides, they might eventually get it to a place where it makes sense to support it. Let Republicans claim they’ve repealed Obamacare, and take solace in knowing that they helped many people who previously had nothing.

It’s likelier that Republicans won’t be flexible, and the negotiations will eventually collapse. But as Republicans proved in 2009, when they dragged their feet through months of disingenuous health care reform negotiations, delay can be its own reward. Many Republicans won’t repeal Obamacare without a replacement in hand; protracted negotiations maximize the chance that Obamacare survives, or escapes maximal harm.

A brave few Democrats, with the best of intentions, should take a look at this “empty facade that would create chaos” before Senate Majority Leader Mitch McConnell pulls it off the table for them.