First, Price has to drive the show. He is the only one capable of getting the White House (more or less) on board. Without a single leading force with one plan Congress can use as a starting point the entire process will slow to a halt (if it hasn’t already). There are dozens of proposals but the GOP needs a single one. Trump may still stab the GOP in the back if the end product is unpopular, but letting Price lead the effort increases the chances the president will stick with the GOP’s plan even if it proves to be controversial.
Second, in keeping with the first rule, Speaker of the House Paul Ryan (R-Wis.) should be quiet for now. His continual assurance that the House has a plan and promises to resolve a myriad of problems (make it cheaper, easier, better) only serve to raise expectations. On PBS NewsHour this week Ryan declared, “Remember the promises of Obamacare: lower prices, more choices. Those things didn’t happen. We believe we can make good on those kind of promises, which is improve access to affordable health care coverage.” There is no plan that will do all that; Ryan should stop insisting there is.
Third, Republicans are setting themselves up for an unhelpful comparison to Obamacare. The standard, whether Republicans like it or not, will be whether people on the ACA, including those getting benefits from expanded Medicaid, can get the same or better benefits for equal or less out-of-pocket cost. That should be the goal, and it may necessitate ideological compromises (e.g., keep the ACA taxes in place).
Fourth, in most GOP plans a tax credit is awarded to all those without employer-provided coverage. The amount of the credit is based on age, not income. That’s well and good, but if they think handing out tax credits to Ivanka and Jared Kushner (and other rich folk) will be popular, they are sadly mistaken. The credits must either taper off or be eliminated entirely for upper-income taxpayers.
Fifth, they need to pay special attention to rural health care. Not only are Americans in rural areas struggling to find providers, but they are also among Trump’s most avid supporters. They tend to vote in off-year elections. Developing a parallel system for Americans in rural and/or blighted areas may win them support on the GOP side (from Sen. Susan Collins of Maine, for example) and put them on the side of working-class voters in distressed areas.
Sixth, the elephant in the room will be Medicaid. Republicans who want to roll it back to pre-expansion levels make a terrible miscalculation. They will be creating hardship stories right and left and making the most vulnerable Americans even more vulnerable. If they want to confound opponents, Republicans should agree to expand Medicaid everywhere, subject to a generous waiver policy that allows states to innovate (e.g., put the poor into regular health-care plans).
When in the minority and out of the White House, Republicans could get by with poking holes in Obamacare and offering elegant, ideologically pristine plans. They do not have that luxury now. If they cannot get on the same page and entice eight Democrats to come along (meaning, for example, they may have to give up a total ban on the use of tax credits to pay for abortion coverage) they will be skewered by their base and likely lose the majority in one or both houses. Letting the perfect be the enemy of the good in this case amounts to political suicide.