The test: What comes after Obamacare?

In September 2009, President Obama called a joint session of Congress to sell his health reform bill. “I am not the first president to take up this cause, but I am determined to be the last,” he said.

He will not be the last.

But those who come after Obama would be wise to heed the lessons of his health reform effort. For Democrats, those lessons are relatively straightforward. It is easy to imagine the next Democratic president passing a health care bill that does four things: expand Medicaid coverage up to 200 percent of poverty, boost subsidies in the exchanges, add a public option that can use Medicare or Medicaid’s pricing power, and let people above age 50 buy into Medicare.

A bill like that could pass the Senate with 51 votes, it would build on what has worked both in America and elsewhere, and it would be straightforward for the government to administer and voters to understand.

Obama’s successor, however, isn’t a Democrat. Trump has often hintedat expansive instincts on health care, praising Canada’s single-payer system, promising he wouldn’t cut Medicaid or Medicare, worrying that the government is getting ripped off by hospitals and pharmaceutical companies, and telling 60 Minutes that “everybody’s going to be taken care of much better than they’re taken care of now” and “the government’s gonna pay for it.”

The plan he has lashed himself to cheerfully breaks those promises, and it is unclear whether Trump realizes it. The AHCA replaces Obamacare while learning nothing from its difficulties. It covers fewer people with less generous insurance, relies on complex arrangements with private insurers, does nothing to address the high prices that drive the cost of US health care, and is being rushed through a hyperpartisan process that ensures Democrats will unwind it as soon as they have the power to do so.

These problems reflect a larger issue the Republican Party must resolve. The Democratic Party’s basic health reform goal is to tax richer people to provide generous insurance to poorer people. This is a broadly popular aim, and many of Obamacare’s problems come because Democrats didn’t lean into it hard enough. The Republican Party’s goals are more diverse, and often less popular.

Fundamentally, Republicans are suspicious of high levels of redistribution in the health care system and frustrated by generous plans funded by third-party payers. GOP proposals tend to envision a health care system based around catastrophic plans and health savings accounts, where people are protected from financial calamity, but otherwise are pushed to shop cautiously for care, and must make do when they simply can’t afford it at all. Republicans want a market where consumers push the cost of health care down, and one reason they push the costs down is because they often can’t afford the pricier options.

There are reasonable arguments for the conservative health care vision, but Republicans don’t make them. Instead, they have attacked Obamacare for being insufficiently generous, for covering too few people, for canceling plans people relied on, for failing to solve the problem of affordability in health care.

While all these criticisms are correct, the Republican replacement plan will make them worse. If it passes, voters are going to find that out, and the reckoning will be severe.

This, above all, is the lesson Republicans need to learn from Obamacare: Don’t overpromise, and don’t mislead.

To the extent that Republicans have a different vision of health care than the Democrats or even the voters, they need to be making that case, and building consensus around a health care system that offers less so it can cost less and tax less. Building that system while promising the opposite will result in disaster, both for them and for the voters who rely on them.