With Barack Obama in his final days in the Oval Office, congressional Republicans on Jan 11. set in motion the process to repeal his signature healthcare law. But in Obama’s farewell address earlier this week, he took a moment to call the GOP’s bluff. “[If] anyone can put together a plan that is demonstrably better than the improvements we’ve made to our health care system, that covers as many people at less cost,” the president pledged, “I will publicly support it.”
That may look like a olive branch from Obama to congressional Republicans determined to tear up his hallmark achievement. But when it comes to providing affordable coverage to more Americans, it’s virtually impossible for conservatives to outdo Obamacare. And the president knows it.
That’s in part because Obamacare, in its basic structure, is the conservative plan for health care reform. There are a variety of ways for a country to provide universal coverage. The government could outright own the hospitals and clinics and employ the doctors—what’s called “socialized medicine,” like in Britain. Alternatively, the government could run an insurance program that pays all medical bills—a single-payer plan, like Medicare.
The most conservative approach of obtaining near-universal coverage is the one Obamacare adopted: private insurers coupled with government subsidies, mandates, and regulations. Obamacare left the insurance industry intact, while prohibiting certain harmful practices like pre-existing condition discrimination and caps on what insurers will pay for. To make insuring the sick a viable business for private companies, Obamacare required everyone healthy and sick alike to purchase coverage, providing subsidies for those who cannot afford it on their own.
There were several reasons why Democrats chose this approach. For one, it was proven to work after then-governor Mitt Romney adopted a similar system in Massachusetts in 2006. After the success of health reform in Massachusetts, the private sector-based “three-legged stool” approach came to dominate the health policy ecosphere.
Democrats also held out hope that importing Romney’s system—which the governor himself poached from the conservative Heritage Foundation—might win bipartisan support. But the months of effort spent by Obama and Democratic leaders trying to win conservative support in 2009 ultimately came to naught, as the GOP denied cooperation as a strategy to stymy Obama.
While Obama’s attempts to court Republicans eight years ago proved hapless, they may be paying late dividends today. Because Democrats relied on the most conservative possible method to achieve near-universal care in 2009, Republicans now have no room to move to the right when attempting to repeal and replace the Democrats’ reform effort. Put simply, conservatives cannot repeal Obamacare and enact a more right-leaning plan that achieves the same quality and levels of insurance.
The GOP has already tipped its weak hand. The “repeal and delay” strategy tacitly acknowledged that cutting off people’s insurance is politically unacceptable and morally unconscionable. And it was also an admission that Republicans do not have a plan coming in the foreseeable future that will make whole all of those covered under Obamacare. After all, Republicans tried to swap out the goal of “universal coverage” for mere “universal access” for a reason.
Even more transparently, the replacement plans that Republicans have produced would almost certainly fall far short of Obamacare. Plans offered by House speaker Paul Ryan and health secretary nominee Tom Price are the culmination of seven years of conservative thinking about how to replace Obamacare. And the dominant feature of those plans is that insurance would get worse. Even though the main conservative complaint about Obamacare has been its effect on out-of-pocket costs, premiums and deductibles would likely only go up under the GOP’s plans. These plans continue to fetishize high-deductible catastrophic insurance paid for by an individual’s own tax-sheltered savings. And they would transform Obamacare’s vilified individual mandate by instead giving private companies the right to price-gouge anyone who is not insured for a spell.
There’s a disconnect between the Republican rhetoric around replacing Obamacare with “something terrific,” as Donald Trump has promised, and the retrograde proposals coming out of Congress. And the source of that disconnect is that conservatives feel political pressure to maintain today’s record high levels of insurance, but don’t actually believe it’s the government’s job to guarantee decent, accessible coverage. Conservative columnist Philip Klein has implored Republicans to stick up for this “simple truth.” And Ben Shapiro, another conservative commentator, took it upon himself to model how to treat health care like regular old commodity, like a “piece of furniture” that’s simply unobtainable to those who can’t afford it.
Even if analogizing vital health services to a chaise lounge wasn’t a surefire political loser, it may already be too late for the GOP to break out of its bind. When replacing Obamacare, Trump adviser Kellyanne Conway said, “We don’t want anyone who currently has insurance not to have insurance.” Republican senator Shelley Moore Capito of West Virginia doubled down on this, saying, “The goal is to get everybody who has insurance—and more—insured.” Trump himself has said that “everybody’s got to be covered” under a conservative Obamacare fix.
Republicans have committed themselves to maintaining Obamacare’s principal aim of broad coverage, obscuring their own conviction that the government has no business guaranteeing health insurance. That’s a testament to the law’s impact. And when they put pen to paper, conservatives will have an exceptionally difficult time drafting a bill that adheres to their ideological commitments of low taxes and minimal regulation while meeting Obamacare’s coverage goals.
Republicans are boxed in, and Obama knows it. Any conservative health reform alternative will be a step backward from Obamacare. As long as near-universal coverage is the metric of success, the GOP won’t be able to beat Obamacare at its own game.