Health Care Compromise: Not Likely!

Originally appeared in The New York Times.

The latest version of the Republican health care bill was unveiled today and within moments, two Republican senators announced their opposition. One more “no” and the bill goes down.

That may lead to renewed talk of the fanciful notion of a bipartisan compromise between the more moderate elements of each party. Before today’s release, Senate majority leader Mitch McConnell even suggested he might reach out to his Democratic counterpart, Chuck Schumer (who has reciprocated by signaling a willingness to work together.)

Yeah, and I’m about to discover oil in my backyard.

The chances of Republicans and Democrats finding common ground on almost any issue are small, and on health care they are infinitesimal.

For one thing, the two parties have become far more polarized across the spectrum of issues. That’s not just an oft-repeated perception; it’s a fact backed up by research.

As the chart below shows, political scientists have used voting records to demonstrate that the degree of extremism in the Congress is greater today than at any time since Reconstruction.

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To be sure, the two sides still manage to agree occasionally. The Senate voted 98-2 to impose tougher sanctions on Iran and Russia. And some kind of compromise involving spending on infrastructure and reform of corporate taxation is vaguely imaginable.

But among the possibilities for common ground, health care isn’t one of them. Deep philosophical differences — particularly as to the role of government — separate the two sides.

Since the passage of the Affordable Care Act, the Democrats have, if anything, moved closer philosophically to the idea of a single-payer program in which the government provides all Americans with guaranteed health care in return for modest premiums, similar to what it does with Medicare.

To a considerable degree, that shift reflects the rising influence within the Democratic Party of its more progressive wing, led by Senators Bernie Sanders and Elizabeth Warren. Their faction believes that a more government-driven policy agenda would have led to a different outcome in the 2016 election.

On the other side, the Freedom Caucus in the House and its fellow travelers in the Senate led by Ted Cruz and Rand Paul want the federal government extricated from the health care sector to the fullest extent possible.

In their minds, regulatory oversight would largely be the province of the states, but even better, the free market would be left to work. In addition, programs like Medicaid would be transformed from entitlements (which just means that every qualified American would receive assistance) to block grants or per capita cap programs, leaving millions unaided.

Some serious people think that gap can be bridged. Really?

Not even the most centrist Democrats — senators like Joe Manchin of West Virginia and Heidi Heitkamp of North Dakota — have shown the slightest sign of backing off from the key elements of the Affordable Care Act.

The Republicans are divided between those who want to flat-out repeal Obamacare and those who want to eviscerate many of its key elements.

The differences between the two sides were not always so great. Remember that the core principles of Obamacare were embraced by conservatives back in the 1990s as a more market-based alternative to the more government-oriented plan promoted by Hillary Clinton when she was the first lady.

And the same conservative principles were adopted by Mitt Romney in his health care plan while he was governor of Massachusetts.

Those conservative ideas still make sense. If Republicans are serious about working across the aisle, they should recall the genesis of those ideas and accept that the fundamental core of the A.C.A. must remain intact.

Sure, some changes — even some alterations favored by Republicans — would make the national health care program work better.

In particular, to keep premiums down, we need to improve the functioning of the exchanges on which individuals not covered by employers can purchase insurance by encouraging greater participation by younger, healthier Americans. Accomplishing that would require greater enforcement of the requirement to buy insurance, including stiffer penalties, instead of the administration’s approach of essentially signaling that no one will be punished for not participating.

But we should also adopt a Republican proposal to scrap the current provision that insurance for older Americans can’t cost more than three times what younger Americans pay (and include higher subsidies for needy older Americans). That was a well-meaning attempt to keep premiums down for those nearer retirement, but instead it has meant prices so high for younger enrollees that many have chosen to drop out.

Other Republican ideas, like reforming how Medicaid services are delivered, are worthy of consideration, but let’s have genuine experiments, not clandestine efforts to eviscerate the program.

Last, the federal government needs to give more certainty to insurers by continuing to fund cost-sharing subsidies (for low-income people to cover their deductibles and co-pays) and help states create adequate reinsurance pools to cushion insurers against losses.

Most important, if the two sides genuinely want a better health insurance system, they need to provide all participants with an assurance that the rules won’t keep changing with every election.