Published November 30, 2023
One of the biggest self-inflicted political wounds of former President Donald Trump’s first years in office was how the Republican Party handled health care. It would later be overshadowed by the Trump administration’s initial response to the pandemic, two impeachments and political violence on January 6, but it’s worth remembering as well.
After years of railing against the Affordable Care Act, and pledging to “repeal and replace Obamacare,” Trump endorsed a Republican effort to unwind the health care law in a rushed and haphazard process.
Trust in the GOP’s health care plan sank, the lack of preparation became clear, and after the late Sen. John McCain gave a final thumbs-down to the effort in the summer of 2017, the party largely slunk away from the topic.
This is a mistake. Health care spending makes up about 18% of our national GDP (by some estimates, twice as much per person as peer nations), and the complexity and expense of the US health care system weighs on families’ minds. Republicans who allow Democrats to be the one party associated with solutions on health care will find — as in the midterms of 2018 — that the lack of a proactive approach to health care will be punished by voters.
For his part, a recent post on TruthSocial suggests Trump is still interested in returning to the fight to repeal Obamacare. “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives,” he wrote. The response from senators who represent different parts of the Republication coalition — from Maine’s Susan Collins and Louisiana’s Bill Cassidy to Ohio’s J.D. Vance — demonstrate how little appetite there is among most elected Republicans for revisiting that fight.
Indeed, while the GOP is fragmented in all sorts of ways, proactive and positive conversations about how to make the US health care system better are quietly occurring away from cable news spotlights.
From scholars like Foundation for Research on Equal Opportunity President Avik Roy to Ed Dolan of the Niskanen Center, a libertarian-rooted think tank in Washington, DC, the conversation has decidedly shifted from repealing Obamacare to figuring out what to do next. The GOP should welcome that pivot.
There are two tracks along which a Republican approach to health care that goes beyond a content-free strategy of “repeal and replace” is developing. The one that has the best chance of appealing to the conservative coalition of today embraces a version of supply-side thinking for the 21st century. “Supply-side” thinking gets a bad rap, associated with tax cuts and theories of “trickle-down economics.”
But in an expensive sector of the economy, like health care, taking steps to increase the supply of options facing consumers can actually help the market function more smoothly. And this way of thinking can appeal to traditional Republicans and more populist types as well. Applying classic conservative principles of a limited government and appreciating the power of markets should mean repealing some of the policies that are in the way of a supply-side approach to health care.
Part of the reason prices for health care services are high is because of anti-competitive behavior by hospitals, drug makers, physicians and health systems, who know that limiting supply and competition in the industry is a safe bet for increasing profits. As a business strategy, it’s logical, but it doesn’t mean policymakers should play along.
One of the most egregious examples of this thinking is “Certificate of Need” laws, a relic of the 1970s that require new health care facilities to obtain permission from state agencies, who are often influenced by incumbent stakeholders, to open. As Aubrey Wursten of the Independent Women’s Forum recently reported, only 15 states have fully repealed laws that restrict competition in health care in this way.
There are other examples of policy-created impingements on allowing the health care market to work better. As policy analyst Robert Orr wrote, fears of a “physician surplus” lead to an artificial cap on medical school enrollments.
In 2020, he found that “the number of practicing physicians per person in the United States is lower than in just about any other developed country.” On top of that, physicians groups like the American Medical Association lobby against laws that would allow nurses and physician’s assistants to perform a wider array of routine tasks, ensuring less competition for these procedures.
Policymakers should push for greater competition by allowing skilled nurses and physicians assistants to perform routine tasks, as well as exploring greater funding for seats in medical schools, revisiting the length and structure of medical schools or allowing more medical professionals from overseas to practice in the US.
More recently, the Affordable Care Act accelerated a growing wave of hospital consolidations and anti-competitive behavior from major health systems. Republicans, traditionally the party that tended to defer to big business, have increasingly signaled frustration at hospitals and doctors’ groups they see as on the wrong side of Covid-19 policies and the culture war.
Supporting efforts, like the bipartisan legislation from Republican Reps. Michael Burgess from Texas, Drew Ferguson from Georgia, and Democratic Rep Debbie Dingell from Michigan to investigate the effects of these mergers should be an easy lift for many Republicans, even the most politically risk-averse ones.
The second track where Republican health care policy thinking is developing is a long-term project. A recent report by the Washington-based consultancy Baron Public Affairs traces some of the health care ideas and principles percolating among the so-called “New Right.” As evidenced by Vance’s interest in making childbirth more affordable, younger and more ideologically flexible, Republicans are looking for ways to make health care more family-friendly.
Their assessment of trends among younger conservatives suggests a growing realization that even with insurance, health care costs and complexity causes too many headaches for too many Americans. As the report notes, “A straightforward step toward improving health care for workers and their families could be making the health care experience — especially billing and customer service — simpler and easier to understand.”
This would require more aggressive regulation and willingness to buck the interests of the health care industry than most elected Republicans have the stomach for now.
Even some of the more modest pro-competition moves face the headwinds of a status quo bias and the unavoidable reality that major industry groups for policies that push costs upward without making health care better — and those groups tend to be generous campaign donors.
America’s convoluted system of health insurance and health care could stand a ground-up reform, but as the political backlash to the — in all, fairly modest — reforms in the Affordable Care Act suggest, that day will be a very long time coming.
In the meantime, Republicans will suffer politically if they return to the messaging of repealing Obamacare. And more importantly, health care will continue to be an albatross around their neck if they aren’t able to offer some solutions that can make finding and paying for health care less of a pain in the neck for individuals and families.
Patrick T. Brown is a fellow at the Ethics and Public Policy Center, where his work with the Life and Family Initiative focuses on developing a robust pro-family economic agenda and supporting families as the cornerstone of a healthy and flourishing society.