In the politics of healthcare reform, past is prologue
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As usual in Washington, it’s déjà vu all over again. You can change the party in charge, and the specifics of the debate, but when it comes to healthcare reform, the tectonic plates shift little over time.

As we head into the second phase of Republican efforts to repeal and replace ObamaCare, a closer look at the forces moving beneath the crust of debate shed light on where we may be going. 

The main issue is this: Is medical care a right or a privilege? 

The answer has drawn a fundamental dividing line in U.S. politics since World War II. 


While the Declaration of Independence included “Life, Liberty and the pursuit of happiness” among our “unalienable rights,” and the Constitution promotes “the general Welfare,” how we deal with the social welfare of individuals remains the province of each generation’s politics.


With war on the nation’s mind, President Roosevelt declared in his 1944 State of the Union Address a second Bill of Rights that included, “The right to adequate medical care and the opportunity to achieve and enjoy good health.”

National health insurance, including Medicare, didn’t happen then, but the employer-based insurance system that conferred healthcare as a privilege of employment thrived after the war.

The approach left many without health coverage, and the debate over filling the gaps for vulnerable populations has raged since.

Twenty years later, GOP presidential nominee Sen. Barry Goldwater warned against “socialized medicine” and questioned, “Having given our pensioners their medical care in kind, why not food baskets, why not public housing accommodations, why not vacation resorts, why not a ration of cigarettes for those who smoke and of beer for those who drink.”

Their enemies may caricature the Freedom Caucus as mean and punitive and the Democratic left as free-spending socialists, but their positions arise from long-held beliefs about the nation’s social compact.

Is healthcare a commodity best left to consumer choice or a government guarantee?

The strength of those beliefs, and the lack of a Congressional center, tells you why it’s hard to cut a deal and move on.

The political economy of healthcare touches the debate at two levels, national and individual. 

Warren Buffett recently told Berkshire Hathaway shareholders “medical costs are the tapeworm of American economic competitiveness.

Most employers share his concern, and they frame the issue this way: “How did we end up with the world’s most expensive healthcare system and get such lousy outcomes.”

Buffet’s colorful comparison aside, most Americans could give a hoot that healthcare will soon consume 20 percent of GDP. Individual attitudes are decidedly micro: “Who cares, what’s in it for me,” or put another way, “can I get it, what does it cost, and what does it cover.”

This is where the public tunes in, and why policy details and trust in government matters.

Little wonder.

The debate is focusing attention on potential losses. Republicans will try to pin a sharp rise in costs on ObamaCare, as Democrats argue otherwise.

Insurance markets are amoral, and they won’t provide much comfort to the responsible party, whether it’s the sponsors of ObamaCare or TrumpCare. 

Commenting on House GOP efforts to alter ObamaCare, University of Chicago professor Harold Pollack’s observed, "You are opening the door to insurers ... trying to avoid covering unprofitable consumers. That puts insurers themselves in a very difficult situation. I don't think they want to be in the business of chasing away sick people as business model.”

Desires aside, they’ve already embraced this business model. Before ObamaCare, more than three-fifths of individual policyholders did not have coverage for maternity services, a third lacked coverage for substance abuse services, nearly two-fifths lacked coverage for mental health services, and about one in 10 lacked coverage for a prescription drug benefit.

The center of gravity in the current debate is in the Senate, and it seems poised to resist House efforts to make coverage requirements a matter of state option.

Politicians have a history of misreading healthcare tea leaves. Nonetheless, it is worth noting that the 10 Democrats up for re-election next year in states won by Trump have condemned the House-passed GOP bill.

West Virginia Sen. Joe ManchinJoe ManchinWhy the Democrats need Joe Manchin Simmering Democratic tensions show signs of boiling over Out-of-touch Democrats running scared of progressives MORE, a Democrat whose constituents overwhelmingly voted for President Trump, offered a blunt assessment to the president. “I said, ‘Mr. President, 172,000 West Virginians got insurance for the first time. They’ve got something they never had before. They don’t know how they got it, they don’t know who gave it to them ... . All they know is they’ve got it. And you know what? They voted for you, Mr. President. They’re going to know who took it away from them.”

Even though House Freedom Caucus members who occupy safe seats may not care, other Republicans had better take notice of the potential political backdraft. "Look, I'm a Republican," Rep. Michael Burgess (R-Texas) told Politico, "I accept the fact that any blame there is to receive, we will receive it.

During the campaign, Trump promised to repeal and replace ObamaCare with “something much better.”

Of late, he stated flatly that premiums and deductibles will go down under a GOP replacement plan. He avoids any mention of trade-offs, and Democrats are already fashioning his words into a double-edged sword to use against him.

The 18 months between now and the midterm elections is a lifetime in politics.

A range of other issues could overtake health care as the center of attention. But if healthcare remains central, Republicans will need to do a better job selling TrumpCare than Democrats did selling ObamaCare.

After ObamaCare passed in 2010, Democrats lost 63 seats in the House and six seats in the Senate. 

Next year, Democrats need to pick up 25 seats to gain control of the House and, as it has before, healthcare could play the decisive role.

Chuck Alston is senior vice president and director of health policy at Qorvis MSLGROUP, a global public relations firm. His firm represents the Blue Cross Blue Shield Association.

The views expressed by contributors are their own and are not the views of The Hill.