I have refrained from writing about health care recently until I could get a better handle on what would happen. It seems I now have a better handle–for now at least. The Senate bill or its iterations was likely doomed to failure for this reason: There were and are at least three factions at cross-purposes:
- Moderate Republicans
- Democrats (almost all)
- Conservative Republicans
We knew the Democrats would vote more or less as a bloc. But the problem was the Republicans. If the bill contained too many conservative elements, the Moderates would vote against it. If it contained too many Moderate elements, the Conservatives would vote against it. Now we have to define what elements are what.
Repealing Obamacare in its entirety is very conservative and drew opposition from Moderates, even when some “sugar” was added to entice them–it only took a couple of no’s. Keeping Obamacare in its entirety was the default that would occur if a vote couldn’t get support to pass, and it is very liberal. However, though many Conservatives wanted to see at least most of Obamacare go, they did not have enough support to make it happen without giving something to their Moderate colleagues. So they lost their votes. When the “skinny” approach was proposed, there was still too much in it that bothered Moderates, who voted against even that, suspicious that the House would double-deal and the Senate would not follow through with leadership promises. Now we are back where we began: Obamacare in full force, though how stringently it will be enforced is anybody’s guess (the Obama administration selectively enforced parts).
The real issue is how to evaluate all this. I am still convinced that (1) Lisa Murkowski voted against the skinny version because she has grown to hate President Trump (not an altogether irrational position, but not exactly mature either) and (2) if the Senate had the entire good of the nation in mind, instead of narrow interests, it could actually come up with decent legislation that would pass, even with no Democrats, but possibly with a few. The key is compromise that moves in a positive direction, even though imperfect. Some Senators have to disabuse themselves of the notion that they can have an ideal, perfect world. What we want is the “best of all possible worlds.”
So what should the Senate do? Come back into session and propose this kind of bill:
- Segregate out (wall off) those people who cannot afford insurance and subsidize them from the General Fund separately and not at the expense of the health care system as a whole. This cannot mean infinite payouts. It would work something like Medicare or Medicaid–not perfect by any means, but only affecting a relatively small number of people.
- For the rest of the population, and even for the poorer, at the same time, create a truly market-driven health care system in which competition is free, across state lines (mandated competition here–no state discretion to prevent it as under the current McCarran Act), regulation of services is minimized to those absolutely necessary, eliminate the taxes, including the Mandate, innovation is encouraged, particularly by just leaving medical care alone to a much greater extent, nudge states to open up medical training to more people and some medical services to different professions (nurses, etc.), allow medical savings accounts, encourage more choice by allowing insurance companies to offer varying plans, etc.
- Allow Democrats to suggest amendments, and if they can move us forward without undue compromise, accept some of them. At any rate, make Democrats have to defend their opposition by giving them an opportunity for “buy-in.”
- Pre-existing conditions: This is still a huge fly in the ointment, but if necessary, give in to cover them, but at the same time, make sure the other cost and competition-enhancing elements are included. The two must go together. That way, even covering pre-existing conditions, though not really insurance anymore, does make more sense.
I am sure I missed something, but the reader will get the main point. Our goal is to shed the terrible Obamacare system with its byzantine regulations and at the same time get a better health care law then we had, even much better, though compromise will be necessary. I would have to see the particular bill to determine whether too much has been compromised. But the approach seems worth it. I still cannot figure what Senators McCain and Paul really want, but I am optimistic (perhaps too much so) that even they would be willing to go a little way. And on the Democrat side, I think Manchin of West Virginia might come along, and maybe some of his more moderate friends.
In the end one does not have to always be an ideological purist, and in politics in the “trenches” one can seldom afford to be a purist. Moreover, it is not a compromise of conscience to agree to non-ideal aspects of a proposal that still move the nation in a better direction from where it was.