Before John McCain put yet another Republican health care plan on life support Friday, I was going to do with the Graham-Cassidy legislation what I've done with previous Republican bills, and weigh the plausible ideas that it contains against its hastily rigged-up architecture and predictable GOP stinginess.
But sometimes, when a party has spent most of a year producing health care bills that excite almost nobody and that even the senators voting for them can't effectively defend, it's worth stepping back and thinking about our national priorities.
This goes for both parties: not only the stepping-on-rakes Republicans but the suddenly single-payer-dreaming Democrats. If Obamacare repeal is really dead for the year 2017, both left and right have a chance to shake their minds free of the health care debate and ask themselves: What are the biggest threats to the American dream right now, to our unity and prosperity, our happiness and civic health?
I would suggest there are two big answers, both of which played crucial roles in getting a carnival showman who promised to Make America Great Again elected president. First, an economic stagnation that we are only just now, eight years into an economic recovery, beginning to escape - a stagnation that has left median incomes roughly flat for almost a generation, encouraged populism on the left and right, and made every kind of polarization that much worse.
Second, a social crisis that the opioid epidemic has thrown into horrifying relief, but that was apparent in other indicators for a while - in the decline of marriage, rising suicide rates, an upward lurch in mortality for poorer whites, a historically low birthrate, a large-scale male abandonment of the workforce, a dissolving trend in religious and civic life, a crisis of patriotism, belonging, trust.
Now a follow-up question: Is the best way to address either of these crises to spend the next five years constantly uprooting and replanting health insurance systems, and letting health care consume every hour of debate?
That appears to be what some on both sides want to happen. The latest Republican plan would push most of Obamacare's funding down to the state level, theoretically limiting the issue's role in national debates. Except that it wouldn't. Every state-by-state fiasco (and there would be many) would bring calls to recentralize, every federal regulatory decision would be litigated furiously, and the issue would dominate the 2020 campaign at the state and federal levels both.
And if the Democrats, having blown up the insurance system once to implement Obamacare, really rallied around a Bernie Sanders-style proposal to do it all over again but on a bigger scale? Then not only would 2020 be a health care election, but if the Democrat won, the next two years would be consumed by outlandish single-payer expectations.
Where would that leave our two big problems, stagnation and the social crisis? Certainly health care is connected to both of them, because everything is always connected. Conservatives will point out that the way health care costs eat into paychecks is part of the story of stagnation. Liberals will respond that universal health insurance helps stabilize and lift up the working class. Conservatives will object that Medicaid reduces workforce participation and possibly subsidizes opioid addiction and that its value to beneficiaries is overstated. And so on.
But when your main challenges involve men who aren't working, wages that aren't rising, families that aren't forming and communities that are collapsing, constantly overhauling health insurance is at best an indirect response, at worst a non sequitur.
There are better options for both parties. Republicans could actually try to govern on a version of the Trump agenda: With one hand, cut corporate taxes and slash regulations to spur growth; with the other, spend on infrastructure to boost blue-collar work, cut payroll taxes and increase the child tax credit, and push to reduce low-skilled immigration. Pay for some of it with caps on tax breaks, let paying for the rest wait for another day.
Democrats, meanwhile, could let single-payer dreams wait (or just die) and think instead about spending that supports work and family directly. They could look at proposals for a larger earned-income tax credit, a family allowance, and let the "job guarantee" and "guaranteed basic income" factions fight things out.
Health care reform was the Barack Obama presidency's main achievement, but it crippled his administration politically once it passed. Obamacare repeal has devoured the first year of the Trump presidency, with nothing to show for it. The country has bigger problems than its insurance system. It's time for both parties to act like it.
New York Times News Service