We are 11 months from a President Trump, Clinton, Sanders, Cruz or Rubio and a final reckoning on what to do with Obamacare. In five years, the House of Representatives has voted more than 60 times to repeal it, but if one of the three Republicans sits in the Oval Office and the Senate remains Republican, this time it would mean something. The Patient Protection and Affordable Care Act would disappear, 15 million people would lose their health insurance and everyone else's insurance would be affected.
Ending the widely unpopular law has been the first goal of the Republican Party and all but a couple of the vast field of presidential candidates. You would expect that, so close to the goal, the remaining five would by now have the outlines of a plan to replace it.
You would be wrong.
In the last GOP debate, CNN interrogators belabored the candidates to describe their plans because all had said they would install something better. It produced the best fireworks of the debates: Marco Rubio taunting the suddenly ruffled Trump for endlessly repeating empty catchphrases. Rubio was right, but no one was much better than Trump. They offered old ideas that are already in the law but unpopular or else solutions that already are a part of Obamacare. But no one dares to say that their popular notions are already part of the law. We have some history of that in Arkansas: provider-reimbursement reforms, the "private option" and now "Arkansas Works," Gov. Hutchinson's plan for "replacing" Obamacare for the poor.
On the Democratic side, both Hillary Clinton and Bernie Sanders would continue Obamacare. Sanders would convert it incrementally into a single-payer system for all. Clinton would make improvements, mostly those that would have gotten into the law in 2010 when the Senate bill and the better House version went to conference, but the loss of a filibuster-proof majority with the death of Ted Kennedy forced Congress and the president to take the Senate bill. Republican majorities since 2011 have made it impossible to change even a comma of the law, and without Democratic majorities in both houses neither Sanders nor Clinton could fix a sentence.
So any change, good or bad, in Obamacare rests with a Republican president. None of the candidates had an answer that should satisfy the most rabid haters or the mildest critics of Obamacare. That is because no one has come up with a workable plan, unless it is to leave 25 million Americans who can't afford the premiums to their own devices. The basic elements of Obamacare — mandatory insurance for individuals and large employers — was the conservative solution, devised by the Heritage Foundation and pushed by Republicans in both houses in 1993-94 and earlier by Presidents Nixon and Ford. The Nixon-Ford plan required all employers to provide managed care for their employees.
His opponents went after poor Gov. John Kasich because when he was in the Republican leadership in the 1990s, he and his colleagues sponsored Obamacare's mandates and Medicaid expansion. Kasich said he now knows better.
Then he proceeded to explain how, as governor of Ohio, he had fashioned changes that expanded coverage and made huge savings in health care. He will bring those reforms to the whole country. Indeed, Kasich expanded coverage in Ohio by implementing Obamacare's Medicaid expansion for childless adults and for children. Left unsaid was that his big reforms in provider reimbursement, which vastly improved patient care, was a pilot project that Obamacare urged states to experiment with in hopes that it would spread across the insurance market. Arkansas led the way in that, too, with similar results. Former Gov. Beebe and Hutchinson never credited Obamacare either, or it would have failed.
Trump promised to replace Obamacare with a plan that insured everyone. No one would die on the sidewalk for lack of medical attention. "How?" Rubio kept demanding. Trump said he would allow insurers to sell policies across state lines, an idea that Cruz and Rubio also embrace. (Actually, Obamacare calls for that, too, in section 1333. Only a few states have enacted the interstate compacts that make it possible.)
For Cruz, Rubio and Ben Carson, the big solution to Obamacare is the individual health saving account (HSA), a version of the old medical savings account. But people have been able to set up HSAs along with cheap high-deductible plans since 2003. Unless you make a lot of money and are young and healthy, they are not very useful and have not proved popular.
I think I see the future of Obamacare under any of these politicians. Mike Beebe and Asa Hutchinson developed the model. Repeal Obamacare, re-enact nearly all of it with new language and tweaks and call it something else. The politics is dubious but it's workable government.