Democrats want to guarantee affordable, quality healthcare to all Americans through government subsidies and regulation. Republicans want to reduce total healthcare spending, including government spending on Medicare and Medicaid, through private market mechanisms that allocate healthcare based on price.
Democrats are from Venus and Republicans are from Mars. There are fundamental differences in the basic health policy goals of the two political parties. That often gets lost in political and media discussion of the healthcare reform issue, argues Drew Altman, CEO of the Kaiser Family Foundation, in an astute new op-ed piece in the Wall Street Journal.
This big difference in goals is all-important in understanding current and forthcoming GOP proposals for replacing the Affordable Care Act, which focuses on expanding insurance coverage and protecting consumers in the insurance market. But in public discussions, “the architects of these Republican plans often gloss over their differences with the ACA,” Altman writes. Health policy experts and the media need to make it clear to voters this year that “the ACA and Republican plans are not different means to the same ends but means to different ends.” And which end you favor depends heavily on your political values and policy priorities.
Given that the two parties have divergent goals, it's tricky to evaluate the GOP plans against the ACA's performance—even though that's ultimately what the Congressional Budget Office would have to do if Republicans ever turn their proposals into legislation.
“Should Republican plans be evaluated against whether they maintain or don't maintain ACA coverage gains and insurance protections?” Altman asks. Or alternatively: “Should they be evaluated on how well they achieve their own objectives—promoting consumer choice and lower-cost insurance plans, reducing marketplace regulation, and reducing federal spending and the federal role in health care?”
Making such evaluation even trickier is that at least some Republicans want to achieve similar goals as the ACA but through different means. The new Health Empowerment Liberty Plan (HELP), authored by Rep. Pete Sessions of Texas and Sen. Bill Cassidy of Louisiana, offers libertarian-leaning proposals to help Americans buy health insurance or self-insure, guarantee they aren't discriminated against by insurers based on pre-existing medical conditions, equalize tax benefits for buying coverage, and create a more competitive healthcare delivery system. It would let people in ACA exchange plans keep their plans and premium subsidies or switch to a new system under which everyone is eligible to receive a $2,500 per person refundable tax credit for buying coverage.
“Someone who repeals (Obamacare) is left with nothing,” Sessions said at a news conference last month to discuss the bill.
Similarly, conservative policy experts in December laid out their own sweeping plan for repealing and replacing the ACA, relying on consumer incentives and market mechanisms. Their complex proposal includes providing age-adjusted tax credits to households without access to employer coverage.
In contrast, a House Republican task force convened by Speaker Paul Ryan is set to release a healthcare reform proposal this month that is expected to include full repeal of Obamacare and restructuring of Medicare and Medicaid. It's not clear what federal subsidies, if any, the task force plan will offer to help people afford coverage.
Presumptive GOP presidential nominee Donald Trump presented no proposals for financing expanded coverage in his seven-point healthcare agenda released in March.
Sen. Orrin Hatch (R-Utah), who backed an Obamacare-like coverage expansion plan in 1993, made it clear that his party's Obamacare replacement plan won't aspire to meet the same health policy goals and metrics as the ACA. “Conservatives cannot allow themselves to be browbeaten for failing to provide the same coverage numbers as Obamacare,” he said in July 2012.
But healthcare industry leaders are impatient with Republican moves to shift national policy away from the goal of expanding insurance coverage. A recent Modern Healthcare survey of 86 top healthcare industry leaders found that more than two-thirds opposed repealing and replacing the ACA.
“I can't see Republicans going away from some type of health program that provides coverage,” said Dr. Larry Hollier, chancellor of the LSU Health Sciences Center New Orleans and head of medical education at six safety net hospitals serving the poor and uninsured throughout Louisiana. “It would be very hard to move away from the coverage people have under the ACA.”