A way forward

The prevailing public opinion on health care, I am convinced, especially in view of the recent partisan debacle, is that Republicans and Democrats in Congress should work together to fix the most unaffordable and unsustainable elements of Obamacare.

The problems are that there are only 90 or so members of the House of Representatives seriously inclined to do that kind of fringe-alienating and primary-inviting work, and only about a half-dozen members in the Senate, and that there is one man-child in the Oval Office threatening to sabotage Obamacare into chaos because he didn’t get to win.

That man-child, Donald Trump, ought to be the greater problem in a saner world. A bipartisan congressional group ought, in that saner world, to prevail.

Ninety House member and six senators, standing strong in the center, could keep anything from happening in either chamber on health care unless Majority Leader Mitch McConnell and Minority Leader Chuck Schumer brought their caucuses their way.

It’s called “the center holding,” which happens when a decisive coalition from both sides of the aisle arrives at compromise policy and leverages it outward. It used to happen all the time, when Congress functioned.

In the House, something called the Problem Solvers Caucus, comprising about 90 moderates equally spanning the New Democrat coalition and the Republican Tuesday meeting group, have pretty much settled on a set of fairly credible proposals offering a little to the left and a little to the right, as reasonable compromise policy must.

When Democrats don’t have majorities, they must compromise. When Republicans can’t undo Democratic policies, they must compromise.

First, these Problem Solvers would mandate funding for the “cost-sharing reduction” subsidies that allow the federal government to reimburse health insurers to lessen out-of-pocket costs for deductibles and co-payments for lower-income persons. Losing those payments would blow up carriers’ and individuals’ costs and probably sink Obamacare.

The Obama administration authorized those subsidies by regulation, and Trump, grumbling, has continued them on a month-to-month basis. But now, spiteful about losing in the repeal-and-replace debate, he is saying he will decide this week whether to discontinue them—as is unilaterally within his preposterous second-place presidential authority—and let Obamacare become so impossibly onerous that Congress would have to pass some kind—any kind—of repeal and replacement.

Working-class voters in Michigan, Wisconsin and Pennsylvania might have voted themselves right out of health insurance.

But mandating those subsidies— freeing them from the madman president’s whim—would avoid catastrophe and allow other elements of the compromise to attack the greater cost problems.

One of those elements is a proposed “stability fund” of federal and state money that states could tap to defray costs for persons with pre-existing conditions. If insurers could be sure that their costs for expensive conditions would eventually be capped, or at least shared by the government, then premiums could better be held down for everyone.

The plan also is to give the smallest businesses a break by defining employers who are mandated to provide coverage as those with more than 500 employees. That’s compared to 50 now. It would define a full-time workweek as 40 hours, as compared to 30 now.

Employees of firms with fewer than 500 employees would go into the exchanges, and, depending on income level, receive subsidies. Small businesses would be helped and the exchanges would be fortified. Those moved into exchanges … well, they most likely would pay more, since a company plan tends to be a better deal than a subsidized exchange plan.

The plan also is to repeal the 2.3 percent excise tax on medical devices, because, you know, Republicans are going to require a tax cut somewhere.

Finally, this plan would make it easier for states to receive federal waivers for innovative programs and to sell coverage across state lines. Arkansas, for example, jumped through hoops to set up its private-option form of Medicaid expansion and then restrict it. This plan would reduce the number and challenge of those hoops.

Here’s what you’d have, then, for liberals and Democrats: Continued individual and employer mandates, continued cost-sharing and premium subsidies on health-care exchanges, and continued Medicaid expansion. You’d have Obamacare, in other words.

For conservatives and Republicans, you’d have: A relaxed mandate on small business, the elimination of a tax, policies sold across state lines and greater flexibility for states to act in the federalism tradition and do things their own way.

The federal-state partnership to help on expensive pre-existing conditions doesn’t strike me as decidedly left or right, but compassionate and actuarial. It’s kind of like the “re-insurance” that Obamacare included initially until Republican litigation killed it. But I suspect that Republicans killed it to try to sabotage all of Obamacare, not from strong specific objection.

Purists on both sides would reject out of hand the elements most appealing to the other. But starting with 90 votes in the center and extending with the leadership’s blessing to add grudging agreement from responsible members accepting that we must do something, even if ideologically imperfect … well, 218 votes might be dimly in sight.

But nobody wants to go home to run in a primary against a challenger pointing out he didn’t repeal and replace Obamacare as promised and accusing him of getting out-negotiated by the no-account Democrats.

It’s hard. Who knew health care was so complicated?

In the Senate, Susan Collins, Republican of Maine, and Bill Nelson, Democratic of Florida, have held a couple of dinners with a half-dozen or so moderate senators from both parties to begin to talk about what they might design.

They’d do well to look at the work of the Problem Solvers in the House.

And they can only hope that this president, whom Collins was caught on a hot mic last week calling “crazy,” doesn’t blow everything up out of resentment that John McCain—no hero to him—wound up getting the one thing this president most wants, which is adulation in the media.

John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, was inducted into the Arkansas Writers’ Hall of Fame in 2014. Email him at jbrummett@ arkansasonline.com. Read his @johnbrummett Twitter feed.