The prospects for repealing and replacing Obamacare are fading rapidly. Senate Majority Leader Mitch McConnell, R-Ky., sensing inevitable failure in the Senate, is already shifting the endeavor to the back burner. The time has come for the Trump administration to make a bold proposal, circumventing the deadlock and shattering conventional wisdom.
President Trump should embrace a new, genuinely conservative version of the single-payer system used throughout the developed world. In the process, by building a new coalition of social conservatives and economic populists, Trump could permanently reshape the political landscape.
The current strategy of Ryancare was doomed from the start. It required the successful threading of a needle from a distance of a thousand yards. Given the razor-thin margins of Republican majorities in both houses, the 60-vote cloture obstacle in the Senate, and the Byzantine restrictions on the “reconciliation” gambit for relying on 50 senators and the vice president, and given that no complicated, Rube Goldberg-like contraption will ever be able to satisfy both the libertarian Freedom Caucus in the House and Republican moderates in the Senate, no plan devised by conventional “conservatives” has any hope of passage.
You cannot simultaneously provide cheap coverage for those with pre-existing conditions, move toward a free market and reduce federal spending. A prudent politician does not attempt the impossible.
We already spend more of the taxpayers’ dollars per citizen on our failed health care system than every country with a single-payer system (with the sole exception of Norway). Let that fact soak in: We could provide every citizen with coverage as good as anything available in Canada or Australia and still reduce government health care spending. In fact, by simultaneously eliminating the huge tax advantages given to health care, we could lower marginal taxes and balance the budget.
How is such a magical solution possible? Because we now have the worst possible system of all — one in which massive federal spending drives up medical costs, while the lack of an elegant, single-payer system deprives tens of millions of the security of coverage and foists the huge burden of costly private insurance on our businesses and industries.
With a single-payer system, the government could use its overwhelming position as the dominant buyer of health care to reduce costs dramatically, bringing both industry profits and physician and executive salaries back to sensible and sustainable levels.
Does this mean that Trump should endorse a Bernie Sanders-like single-payer system, similar to what has been proposed in California? Absolutely not.
Trump should propose a “conservative” version, one that offers protection only for catastrophic illnesses, whether new or pre-existing. The system should have a large, income-adjusted deductible (10 percent of adjusted gross income), and it should pay only for essential care — care that significantly extends life or sensory or skeletal-muscular functioning.
Trumpcare should explicitly exclude all social engineering disguised as “health” care, including abortion, contraception and “gender-reassignment” surgery.
This would accomplish two things: It would keep Trumpcare cost-effective (at levels no greater than current government spending, including lost tax revenue), and it would attract firm and enthusiastic support from America’s religious groups, especially Catholics and evangelicals.
Finally, Trumpcare should respect the freedom of the individual states to add to the bare-bones coverage as they see fit, with an expected two-thirds federal and one-third state balance (as in Australia).
The proposal would be incredibly simple, with almost no administrative overhead. It would provide a true safety net for all Americans, thereby pre-empting any Democratic campaign toward socialized medicine. By using the new bargaining power of the government as dominant consumer, Republicans could finally bring health care costs under control, from 16 percent of GDP to something like 10 percent, ending the long-term Medicare-Medicaid fiscal crisis.
Trump could use his proposal to divide the Democrats in Congress, forcing them to choose between one of their highest and longest-held goals (guaranteed health care for all) and their allegiance to the “transgressive” agenda of abortionists, transsexualists and zero-population-growth fanatics. Even if the proposal fails, it will give Trumpian reformists a positive and popular platform to run on in 2018, in both the Republican primaries and the general election for House and Senate seats.
Trump cannot afford to outsource his agenda to the conventional GOP leadership of the House or the Senate. He must, like Benjamin Disraeli, the great British conservative prime minister of the 19th century, make his own mark, expanding the welfare state in a way that enhances conservative social goals while securing the political support of the working class for another generation or two.
Trumpcare would be the greatest pro-life victory in our history. It would also marginalize the libertarian wing of the GOP, including Sens. Ted Cruz and Rand Paul, and the Freedom Caucus, giving Trump the advantage of governing from a broad center instead of a razor-thin, fractious coalition on the right.
Robert C. Koons is a professor of philosophy at the University of Texas at Austin.