Very little is going well for Republicans when it comes to healthcare.
But this was a predictable predicament.
When ObamaCare was conceived and written, mostly by the late Sen. Ted Kennedy’s (D-Mass.) policy staff, its clear goal was to dramatically expand the number of Americans who would receive some level of subsidized health coverage.
The original idea was to bring as many people as possible into some form of government-supported healthcare.
The reason for doing this — beyond the fact that it met the liberal aim of expanding coverage to people and having someone else pay for that coverage — was the belief that it would push the nation closer to a single-payer system.
The left hoped that if you combined those covered by Medicare and the VA with the expanded coverage of Medicaid and the subsidized coverage received by those who were pushed into exchanges under ObamaCare, you would close in on the critical mass needed to flip over into a single-payer system.
Further, since all of the expansion put in place under ObamaCare was grossly underfunded, the left believed there would be massive financial pressure to move to a single-payer system. That move, they believed, would come to seem the most viable means of controlling the accelerating costs of the various federally-subsidized health services.
This game plan has worked at two levels.
First, millions of people have been brought into some form of highly subsidized healthcare coverage.
Second, the cost to the federal government driven by ObamaCare subsidies has exploded.
This is the hand that the Republican Congress and the Trump administration now hold. It is a weak hand.
It is compounded in its weakness by certain rules of governance.
First, the people who now receive subsidized healthcare, whether through the Medicaid expansion or via the federally-underwritten exchanges, are not going to lose their coverage.
This is a political reality. Elected representatives in democracies do not take things away from people and get reelected.
Second, subsidies — especially those involving healthcare — are very expensive and will continue to grow due to the nature of healthcare delivery, which has few incentives that constrain its costs and many factors that expand those costs.
Republicans can continue to circle the wagons around the idea of repealing ObamaCare, but that point has long become moot in the face of the core issues with which they are now confronted.
Most Americans — those outside the Beltway — do not care if ObamaCare is repealed.
Those Americans who have healthcare simply want to keep their healthcare and have it be affordable.
To state it another way, voters who have some form of subsidized healthcare expect to keep it.
There is, however, the opportunity for Republicans to turn these realities into positive policies.
First, Republicans should not be making repealing ObamaCare their battle cry.
The Democratic leadership on healthcare is now epitomized by Sens. Bernie SandersBernie SandersManchin suggests pausing talks on .5 trillion package until 2022: report Yarmuth and Clyburn suggest .5T package may be slimmed Sanders calls deadly Afghan drone strike 'unacceptable' MORE (I-Vt.) and Elizabeth WarrenElizabeth WarrenThe Trojan Horse of protectionism Federal Reserve officials' stock trading sparks ethics review Manchin keeps Washington guessing on what he wants MORE (D-Mass.), whose aim is still to fulfill the real dream of ObamaCare: a single-payer system.
This is the fight Republicans should focus on. Single-payer systems do not work. They are rationing by another name. Republicans should be making this the issue.
Second, Republicans need to accept the inexorable fact that healthcare is the most expensive and fastest-growing element of federal spending.
There needs to be a rational way to pay for these costs so that the deficits and debts of the country do not explode.
ObamaCare placed the burden of paying for expanded healthcare coverage on high income Americans. It was a simple act of class warfare. It is the essence of the left’s dogma: give out a benefit to the many and have someone else pay for it.
But it does not work because, as Margaret Thatcher succinctly put it, the problem with socialism is that at some point you run out of other people’s money.
This is what is happening with healthcare. Constantly raising the burden on the few cannot keep up with the federal government’s expanding healthcare appetite.
Instead, most of the federal costs of healthcare are now being paid for by increased borrowing. This approach is inherently destructive to growth and job creation in a market economy.
Republicans should initiate a funding mechanism that not only supports those whose subsidies are not going to be removed, but will actually pay the reasonable costs of providing quality healthcare under Medicare and Medicaid.
Such a system would involve a charge (less than one-tenth of one percent) on all healthcare costs — essentially a user fee that would be spread across a massive base, and so be very low in percentage terms.
Although fees tend to be anathema to conservatives, running up the debt to pay for the costs of services to people who are being subsidized is significantly worse.
At least with this approach, two major issues are addressed.
First having the cost of healthcare paid for in a logical way mutes the primary driver of the federal long-term debt, healthcare costs.
Second, the Republicans actually do solve the healthcare conundrum they have been handed. They can ensure that we have a viable healthcare delivery system while escaping the trap of moving to a single-payer system.
Judd Gregg (R) is a former governor and three-term senator from New Hampshire who served as chairman and ranking member of the Senate Budget Committee, and as ranking member of the Senate Appropriations Foreign Operations subcommittee.