The Washington PostDemocracy Dies in Darkness

Opinion The GOP is playing catch-up on health care. It needs some fresh ideas.

North Carolina House Speaker Tim Moore speaks alongside fellow state Republican leaders in Raleigh, N.C., on March 2 about a Medicaid expansion agreement. (Hannah Schoenbaum/AP)
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Just a few years ago, Republicans were clamoring to repeal the Affordable Care Act. Today, not only has opposition to the law largely disappeared from the party’s messaging, but some Republican states are using it to expand Medicaid, as North Carolina did this week.

This is a stark illustration of how far the party has come — and its need for fresh conservative thinking on health care.

Abolishing Obamacare was a rallying cry for Republicans for years until the party gained complete control over federal legislation with Donald Trump’s victory in 2016. At that point, they could have fulfilled their campaign promise to do away with the law. They failed to do so in spectacular fashion in 2017, with three GOP senators opposing even a slim bill that would have punted the hard questions of a repeal to a House-Senate conference committee.

At the core of the GOP’s failure was its refusal to address the real issues that a repeal would entail. For better or worse, millions of people have become dependent upon Obamacare for their health insurance, either via national health insurance subsidies or the Medicaid expansion. The health-care industry also started to restructure in response to some of the law’s less publicized measures, such as the creation of accountable care organizations, which brought physicians and hospitals into close coordination. Seven years after Obamacare’s passage, the GOP had no idea how to approach the challenge of undoing these provisions.

This has left Republicans mainly playing catch-up on health policy. Ten states remain holdouts regarding Medicaid expansion, but North Carolina’s move means almost every swing state now has expanded the program. Georgia Gov. Brian Kemp (R) has proposed a limited expansion in his state to allow the program to cover individuals earning up to the federal poverty limit, which fellow swing state Wisconsin already does. That leaves only a few deep-red states, mainly in the South, with the pre-Obamacare Medicaid rules.

This slow movement mirrors the ideological shift among voters. Seven states have approved Medicaid expansion via ballot initiative in the past five years, including in Republican bastions such as Nebraska, Oklahoma and Missouri. South Dakota became the most recent red state to do so last November when 56 percent of state voters backed the move. Republican Gov. Kristi L. Noem, who opposed the proposal, won reelection with 62 percent, demonstrating that many solid Republicans favor expansion.

That puts Republican officeholders in a quandary. Large majorities of voters nationwide, including most swing voters, support extensive public subsidies for health care. But party activists and donors remain at best resistant to this fact and at worst openly hostile to it. Republican officeholders in recent years have generally responded by doing as little as possible so as to anger neither.

The better course would be to accept where the public is and work with it. That means thinking through the tough questions many would rather avoid, such as reforming subsidies and how health-care providers are regulated.

Conservative health-care policy experts have plenty of ideas to offer. Most advocate more use of deregulation and market forces to improve health-care delivery and efficiency, which would allow the expansion of health insurance coverage without breaking the bank. The American Enterprise Institute’s James Capretta, for example, has been beating this drum for decades and recently edited a comprehensive volume of proposals along this line. The Manhattan Institute’s Chris Pope is a similarly innovative health-care thinker whose ideas can help the party craft a new agenda.

The party should also do more hard thinking about who deserves public subsidies to purchase health insurance. Most people would probably agree that those who can afford health insurance shouldn’t get public help. But current policy does exactly that. Private health insurance premiums paid by employers are exempt from income tax no matter how much an employee makes, and Medicare Part B premiums are heavily subsidized no matter how much seniors have in the bank. Fiscal conservatives and populists should be able to agree that taxing the working class to help pay for the health-care needs of wealthy retirees is bad public policy.

Making this shift on health care will help the party retool in other areas as well. Americans, including large numbers of Republicans, want an expansive welfare state. They want well-funded public education, subsidized medical care and a secure retirement program. They are risk-averse when it comes reforming such programs, a major impediment to small-government conservative goals. But they do want innovation and private-sector opportunity.

A healthy Republican Party would embrace that combination of preferences and focus on delivering the goods. Voter support for Medicaid expansion should hasten the party’s recognition of that fact.