Since the election in November, most political commentary has been focused on President Donald Trump and the many ways that he has differed from past presidents. In contrast, the brewing fight over healthcare marks a return to pre-Trump Republican versus Democratic political debates. Now is the first time that Republicans hold the House, Senate, and Presidency since the Affordable Care Act (ACA) was signed into law in 2010. Since the ACA was signed into law, Republican lawmakers have campaigned extensively on its total repeal and have the congressional record to back it up. Now, and despite surface-level enthusiasm for unified control of government, many Republicans are finding it harder to vote for a full repeal of the ACA now that it would actually become law.
Put simply, the Affordable Care Act was passed with the intention of improving quality of health insurance and making it more accessible to uninsured Americans. The policies of the ACA are often described as a “three-legged stool,” consisting of the guaranteed issue of insurance regardless of preexisting conditions, the individual mandate to purchase health insurance, and tax subsidies for those unable to afford insurance. Advocates for the ACA contend that without the three “legs,” the goals of improved quality and a lower uninsured rate would not be possible. In addition, state-based exchanges for the sale of insurance were established and Medicaid was expanded to cover individuals earning less than 133% of the poverty line. After a year of debate amongst the short-lived Democratic supermajority, ACA was the first major federal overhaul of health policy since the creation of Medicare and Medicaid in 1965.
On Monday, Speaker of the House Paul Ryan and House Republicans unveiled their plan to repeal and replace the ACA—a bill called the American Healthcare Act (AHCA). Republicans have campaigned against the ACA vigorously over the past 8 years, but have largely publically supported the goals of the ACA—improving quality at lower costs and making insurance more accessible. However, the plan proposed by Speaker Ryan appears to do less to achieve these goals than the ACA. This is not a judgement of soundness of policy—the AHCA fits squarely in line with Ryan’s past statements regarding healthcare policy and general Republican ideology. It is a fair generalization to make that Republicans generally advocate for less market regulation and lower transfer payments from high to low income individuals than Democrats. In terms of healthcare specifically, conservative economic thinkers do not believe it is right or efficient for the government to guarantee healthcare for all Americans. But in a time where most Americans believe it is the responsibility of the federal government to guarantee healthcare coverage, it is politically unwise to state that one does not believe it is the government’s responsibility to do just that. This dissonance was sustainable when the Republican Party was in opposition and did not have to present a meaningful alternative to the ACA, but now that they control government it is a significant issue.
The result of the ACA is that health policy will be largely judged, fairly or unfairly, by the rate of uninsured Americans and the costs of health insurance. If these are the terms by which healthcare policy is judged, the Republican-controlled government will never be able to pass a suitable improvement to the ACA.
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