The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task.
But the battlefield under Price’s feet has shifted substantially in the past few weeks. Republicans have splintered, the timeline for repeal has dragged on and on, alternative plans have propagated in the fertile soil of disunion, and some have lost their resolve. And in the turmoil over the fate of Obamacare, the idea of universal health care has emerged as a third way among voters in both parties. The health system the mainstream GOP opposes most is now one some of its voters support—potentially making Price’s task of replacing Obamacare all the more complicated.
The political appeal of a single-payer, universal health-care system is perhaps best outlined by Jessi Bohon, a high-school teacher who attended a raucous and often angry town hall with Republican Representative Diane Black in Murfreesboro, Tennessee, last week:
Bohon was able to ask Black a question, and she began with a defense of Obamacare. “As a Christian, my whole philosophy in life is pull up the unfortunate,” she said, referencing the law’s individual mandate and how requiring healthy Americans to purchase insurance lowers costs for the sick. But Bohon went a step further in her support of expanding coverage and her criticisms of the private insurers who’ve complicated the law: “Why don’t we expand Medicaid, and have everybody have insurance?” she asked.
It’s possible that Bohon’s question was simply an attempt to ask Black to implement policies that already exist in the Affordable Care Act. States have the option to expand Medicaid to more low-income adults under Obamacare, though Tennessee, among others, has chosen not to accept federal funds to do it. But her query and criticisms of market-based plans raise a broader question: Why rely on private insurers at all?
Senator Bernie Sanders had also made the case for government-run health care in a CNN debate on Obamacare just the night before. Although he was ostensibly brought on to defend the law against interlocutor Senator Ted Cruz’s criticisms, Sanders used his platform to argue for Medicare for all. His strategy was not to forcefully defend the law against critiques from Cruz, CNN, and the audience; rather, he often agreed with Cruz that those critiques were valid. But his solution undercut Cruz’s message of limited government. Why continue a system that relies on premiums at all, Sanders asked—and why continue to enrich insurers that simply cannot be relied upon to act in patients’ best interests?
Although Bohon—a self-identified Hillary Clinton voter—and Sanders certainly represent liberal sensibilities, several polls show that universal coverage is gaining traction among Democratic and Republican voters. A January Pew Research Center survey showed that 60 percent of Americans believe that government “should be responsible for ensuring health-care coverage for all Americans”—the highest mark in nearly a decade—though they are divided on whether government should be the sole provider of insurance. The recent increases nationally in support for universal coverage are mostly attributable to low-income Republicans. Over half of all Republicans surveyed who have family incomes of less than $30,000 agreed with the idea. Twenty-eight percent of all people polled in a recent Gallup survey expressed support for a single-payer system run by the government.
To be sure, the conclusions that can be gleaned from the polling here are a bit murky. Last year, my colleague Olga Khazan explored how support for a single-payer, Medicare-like plan decreases dramatically when such a plan would necessitate tax increases, which it almost certainly would. Also, a Kaiser Family Foundation survey from February 2016 showed that the label matters as well. Over 70 percent of Americans support Sanders’s “Medicare for all” plan. But they weren’t as enthusiastic about “universal health care” or “single-payer” health care. Although there are some real potential differences in these concepts that voters might be responding to—the term “universal health care” doesn’t specify financing or delivery, and “single-payer” doesn’t specify how the scheme is actually administered—the KFF poll potentially illustrates that there are barriers to understanding whether the public actually wants and understands a universal health-care system.
Still, the upswing in support for the government provision of health care among low-income Republicans provides a real opportunity for politicians in both parties. Trump himself once promised to implement “insurance for everybody.” Though it’s easy to view that one-time vow as fluff or a misunderstanding of his own party line, it could be a lifeline for Republicans facing revolts back home in poor districts where constituents are fearful of losing their insurance coverage. An Obamacare replacement with an expanded public-insurance system would follow through on promises to repeal the ACA. And it could also replace an unstable and weakening exchange system—dominated by reviled insurance companies—with Medicare or state-branded Medicaid programs like Kentucky’s Kynect, which tend to be widely trusted.
That route might be too far-fetched or expensive for Republicans to pursue en masse. Although their current repeal plan might bend Republican rules on passing legislation that increases the deficit, demolishing or controlling health-care markets and extending tax-funded insurance would be outright heresy against the party line. The resistance to such an idea in the health-care industry, and among its lobbyists, might threaten Republicans in Congress who rebel, thereby reinforcing the market-based status quo.
But it’s not too far-fetched for Democrats, who could, by embracing universal coverage, force Republicans to at least consider altering the party line. Democrats don’t face the same political risks with health care as Republicans do, not only because universal health care exists within liberal theory of government, but because a Republican-dominated Congress effectively renders many of their platforms, votes, and draft bills symbolic. The same dynamic in reverse created the anti-Obamacare fervor among congressional Republicans in the first place, and has been one of the largest factors in the GOP’s electoral strength since 2010.
Were they to take the plunge, Democratic candidates could run as challengers in upcoming elections on a third way of health reform: neither extending unpopular pieces of a program nor rolling back coverage, but giving everyone Medicare. And if the Democratic Party were to support universal health care, that might put pressure on Republicans, who wouldn’t want to lose voters who fear loss of coverage or doctors under a massive repeal.
Thus the precariousness of the Republicans’ position. With Price atop the national public-health system and already empowered by an executive order from the White House, Republicans in the executive branch and Congress have run out of excuses to do the job they came to do. But they face an ever-mobilizing opposition that extends across both parties, and immediate decisive action carries significant risks of causing a conflagration if people lose coverage. Paradoxically, delays give more time for the party to splinter and lose momentum, and for the idea of universal care to take root as a viable alternative as the stresses of an unfixed existing system mount. For at least some Republicans, that option might now be the most attractive now.