Not so long ago, much of the Republican Party stood united in a vision for health care. For 20 years, Party leaders from across the political spectrum coalesced around elements of a plan that would use the private market to broadly expand coverage.
The plan looked something like this. All Americans would be subject to a mandate to obtain health insurance for themselves and their families or pay a penalty along with their taxes. Most employers would be mandated to offer insurance to their workers. Those without access to employer-sponsored coverage would buy policies on an exchange directly from insurance companies, and insurers would be required to offer coverage regardless of an applicant's health status. Subsidies would be available for those with low incomes, and those who were very poor would receive coverage under an expanded Medicaid program.
Sound familiar? It is the essence of Romneycare, the health reform plan enacted in Massachusetts in 2006 with the support of Republican governor Mitt Romney.
Romneycare emerged after more than 15 years of Republican efforts to implement such a system. It was originally devised by the Heritage Foundation, a conservative think-tank, in 1989. The concept was supported by 21 Republican senators in 1993, including many moderates, when it formed the basis of the Health Equity and Access Reform Today Act, an alternative to the Clinton plan that was then being debated in Congress.
And the concept formed the basis of a plan proposed in 2009 by two conservative Republicans, Representative Paul Ryan and Senator Tom Coburn, the Patients' Choice Act.
Of course, as you undoubtedly recognize, the Republican market-based plan is at the core of the Affordable Care Act.
What happened when Democrats signed on to the approach? The Republican consensus immediately evaporated. Even Heritage turned against its own handiwork. As soon as the ACA was enacted in 2010, Republicans in Congress announced unbending opposition and began an unrelenting effort to "repeal and replace."
But seven years later, that promise remains little more than a slogan. Republicans voted more than 60 times to repeal all or part of the ACA while Obama was president, knowing their votes were merely symbolic, since he was certain to veto any legislation that emerged.
And now that they control both houses of Congress and the White House and have the chance to actually bring a plan to fruition, they can't figure out what they want.
Republican conservatives want to eliminate any trace of the ACA, even if it means denying lifesaving health care to tens of millions of Americans. Moderates want to insure that whatever form a replacement takes, the ACA's coverage gains are largely maintained. The Republican health care bill that failed in the Senate this week, the Better Care Reconciliation Act, meets the goals of neither wing.
President Trump can't seem to decide what he wants, either. He promised at the start of the presidential campaign that he would not reduce Medicaid spending, but his budget proposal includes major cuts.
The only unifying theme in Republican positions today is a desire to dismantle anything created by President Obama and his Democratic colleagues, even programs based largely on their own principles. That is hardly a vision for constructive public policy.
Crafting a complex government program requires painstaking work, including the arduous task of consensus building. It is not accomplished by hatching a plan through the secret deliberations of 13 senators, as Senate Republicans did in crafting the BCRA, and then rushing it to a vote.