How many versions of health care reform have Republicans tried -- and failed? Here's why they are unable to craft anything that will work, over and beyond their internal division of moderate-conservative disagreements.
Obamacare is based on several irreplaceable principles. It's not just a plan someone thought up; it evolved over years of work, months of negotiations, and hundreds of hours of meetings -- finding solutions to the anticipated problems. A plan has to include them all to work properly.
Even so, one of them was taken away by the Supreme Court when it ruled unconstitutional the part of the plan that penalized states for not expanding Medicaid as part of the plan. Consequently, many states opted not to, which has hurt the effectiveness of Obamacare by reducing the number of people covered.
Fortunately, it has managed to survive and now is stabilizing, in spite of the sabotage Republicans have inflicted on it. (See ShrinkRap 7/15) Indeed, Trump still threatens to withhold the subsidies, leaving insurers in limbo and not knowing what to they need to charge.
Republicans don't accept those principles, so they try to write a plan without them or that short-changes them. Then they turn the plan into a tax cut program, mostly for the wealthy. So that's why they can't make it work.
Here are those principles:
1. The basic principle of insurance: spreading the risk for mutual benefit. In order to accomplish this, you need broad (ideally universal) coverage that includes young and healthy individuals, spreading the risk among people who will use it a lot and people who will never need it, or at least people who may not need it until many years later. This is the way premiums can be kept down overall. Otherwise, only people who need it a lot (sicker people) will sign up, which makes the premiums skyrocket.
In order to get such broad coverage, there has to be some inducement, like a penalty, for not participating. Or else you can do it by actually making it a program covering everyone and paid for by taxes. That would raise taxes (anathema to Republicans), but the extra tax would be more than offset by having no insurance premium to pay for. It's the most efficient way. It's called universal coverage. Politically, the Democrats knew they couldn't get that passed, so they settled for the penalty, which has not been popular -- but is necessary, for the plan to work. Republicans want to eliminate the penalty.
2. Health care is considered a right of all citizens. We're gradually, as a society, coming to accept that. Many Republicans do not agree, however. This is crucial when it comes to how premiums are calculated for individuals.
Pricing of premiums cannot be based on individual risk. If so, young healthy people would pay very low rates; but sicker and older patients would have to pay rates that most could not afford. And young people will some day be old people -- then they'll not be able to afford what was so cheap when they didn't need it.
Then you get premiums going up for people who use the insurance; and they can't afford it when they need it most; or, worse, the insurance company cancels your policy. That defeats the whole purpose of insurance. Yet, if premiums are too high, young healthy people will not buy it.
So there has to be a compromise, the best probably being a small increase based on age; but not too much or you price out the older people who need it most. Also, it cannot exclude people with pre-existing conditions -- for the reasons given above. If health care is a right, you don't lose that right because you've been sick. But that's what happens when insurance excludes coverage for those who your have been sick before.
3. Government assistance for those who cannot afford it. In Obamacare, this comes in the form of subsidies for those who fall between Medicaid and a certain income level. Republicans hate having the government set up another "entitlement," as they disapprovingly call it. Instead, they're offering a little help as tax credits, which don't do much for those who don't even pay taxes. And Trump may even just decide to stop paying the subsidies, thus further sabotaging what is working.
So this doesn't cover all the details, but in big principles, this is what Obamacare does, and what it requires. Unless we could just skip on over and adopt universal, single payer -- or a Medicare-for-All plan. I think all of this controversy has educated the public, and the American people have moved significantly closer to accepting universal health care. But the politicians have to go through another step of failure before we can get to that better plan.
Republican politicians have been promising for eight years that they would "repeal Obamacare," which they have turned into the devil incarnate. So they can't just give up and accept what they have demonized. They're stymied by their own rhetoric.
As to the three basic principles: (1) Republicans more or less accept the principle of insurance, sharing the risk; but they'd rather have the government minimally involved. And avoid, if possible, having to provide help for those who can't afford it. (2) Health care as a right for everyone -- that's not acceptable to many, perhaps most, Republicans. Remember though: Republicans in the past have advocated for very liberal health care plans. Obamacare was largely based on Mitt Romney's plan when he was Massachusetts' governor, (3) Government assistance to needy people is tough for Republicans to accept. They want to weasel out by turning it into block grants for states -- and avoid the guilt of seeming stingy. Or turn it into a private sector plan that gets it out of government hands. Just not more "safety net" programs that "encourage dependency."
But they can't plan something that works that isn't Obamacare. So, I repeat my suggestion, which nobody seems to be considering. Make the small changes that Obamacare needs to make it work better -- and let the Republicans change the name to something else. Then you can say they "repealed and replaced Obamacare." How about calling it the "Affordable Care Act II"? Or something neutral, like "Healthy America."
Just don't ruin it. I think we'd even be willing to let them claim credit for a better working plan (we all know the history), if they just don't ruin what is proving to be a very good thing.