Most Republican policymakers have always opposed universal health coverage or anything close to it. That opposition has many roots – preferences for less government; for markets over regulation; for tax cuts; or possibly for more defense spending.
Or, perhaps it just has been about the money. Republicans simply have not wanted to provide the financing necessary to get more health care to an overwhelmingly low-income, uninsured population.
But, whatever the causes of their opposition, Republicans have never had to acknowledge it. They rejected President Bill Clinton’s proposal that employers be required to purchase insurance and President Barack Obama’s advocacy of a requirement that individuals have insurance. Republicans routinely condemned “single-payer” or “Medicare for all” coverage expansion.
Ideologically, they rejected it all as “big government,” as an imposition on business or restrictions on individual choice.
It was a strategy of opposition that never required them to produce a serious proposal of their own. For them there was only a wrong way, but never another way. They simply did not want or need one.
Today, however, Republican policymakers are confronting a much more sizable policy challenge. More than 20 million Americans now have health insurance than was the case before the Affordable Care Act. Many more are protected by new rules on pre-existing conditions, the right of young adults to remain on their parent’s policies, or other Obamacare provisions.
And, while support for Obamacare in general remains about 50 percent, many core elements are supported by very sizable majorities.
As a result, repealing Obamacare without a replacement is off the table. The disruption would be far too great for far too many. Many Republicans are now recognizing that a replacement plan may have to guarantee that those who have health coverage can keep it.
These new realities seem to have Republicans boxed in. For the first time, they are being challenged to produce a serious, credible proposal that will, like Obamacare, support significant coverage expansions and withstand public and expert scrutiny. In short, Republicans will need to make and defend a case, rather than undermine one – always the harder challenge in policymaking.
Their initial offering, recently proposed by House Speaker Paul Ryan, is unlikely to come close to meeting that challenge. It includes major cuts in the Medicaid program, the backbone of care for low-income Americans. It proposes equal-sized tax credits for all – with the very wealthy getting the same credit as middle- and lower-class families – rather than directing subsidies to those in need as provided by Obamacare.
Ryan’s plan also promotes Health Savings Accounts, which clearly offer the greatest benefit to those with the highest incomes and tax rates and the least benefit to low-income individuals who are less equipped to take advantage of the tax deduction.
Overall, while the proposal does not offer any specific numbers or projections, it is unimaginable that such a policy will add up to true expansions in health coverage. In this proposal, the redistribution from higher-income earners to lower-income earners that is required in almost any coverage expansion seems headed in the wrong direction.
Republicans easily have the votes to repeal Obamacare, but they are not ready to cast them. They need a replacement strategy that comes close to maintaining current levels of coverage but the policies they seem willing to support cannot achieve that goal.
Walter Zelman chairs the Department of Public Health for California State University, Los Angeles. He can be contacted at firstname.lastname@example.org.