Republicans are focused on trying to minimize taxes, especially on investment income, and keeping federal subsidies for health care to a minimum. They are willing to accept the wrenching consequences that attaining those goals might have for Americans’ insurance coverage, betting that lower taxes and smaller government will fuel a more vibrant economy.
This contrast is evident in both the content of the two bills and some of the choices the parties’ leaders have taken in pursuing them.
The Republican bill, which the Senate intends to vote on next week, has been cast as the Obamacare repeal bill. But it leaves some significant parts of the Affordable Care Act intact and has some provisions that change health policy that aren’t really about the 2010 law. Those details shed light on the underlying goals of Republican leaders apart from simply being able to tell their supporters that they repealed Obamacare.
The bill, for example, eventually eliminates the expansion of Medicaid that was a major part of the Affordable Care Act. But it also goes further than that, imposing caps on Medicaid’s spending per recipient. This shrinks the entire program, significantly reducing the federal government role.
In other words, it’s as much about changing the very nature of the Medicaid program — away from an open-ended promise from the federal government and toward a narrowly constrained program — as it is about undoing provisions of the Affordable Care Act.
It’s also telling which parts of Obamacare are being tweaked, and which are being fully repealed. Tax subsidies to help the middle class pay for health insurance under the Affordable Care Act are being reduced, not eliminated. But the tax increases for high-income Americans that Democrats used to help pay for the Affordable Care Act are being scrapped entirely.
A 3.8 percent tax on investment income over $250,000 for a couple would be history, as would an 0.9 percent surcharge on payroll tax above that same level. The Tax Policy Center estimates that would amount to an average tax cut of $54,000 for households making over $1 million.
Finally, in parsing what Republicans really value most in health policy, there is what they didn’t do. The Congressional Budget Office estimated that the House’s version of this legislation would reduce the number of people with health insurance by 23 million; similar estimates of the Senate legislation are expected next week.
But there’s not much evidence that congressional Republicans see those estimates as a reason to devise a new plan that would keep more people insured. Rather, they are barreling ahead — the House voted on its version of the plan before the C.B.O. numbers on the latest version had even been finished.
Then there are the Democrats.
Republicans have shown willingness to do whatever it takes to achieve goals of less federal spending on health care and lower taxes; Democrats have, conversely, displayed a similar approach to get to the goal of more widely available insurance.
In 2009, the Obama administration was focused on cobbling together the votes for a program to expand the availability of insurance, through any path it could find.
That meant negotiating with the health insurance industry to keep its central role in the United States health care system, even as some on the left wing of the Democratic Party would have preferred shifting to a single-payer system in which the government would supplant private insurers.
It meant including the tax increases that Republicans now seek to repeal in order to keep the proposal from blowing out the budget deficit, soothing deficit hawks.
The Affordable Care Act included other provisions that angered some on the left, such as a so-called Cadillac tax (disliked by labor unions) on expensive health insurance plans, and a powerful board focused on reducing the growth of Medicare costs over time.
Congress and the Obama administration did extensive back-and-forth with health policy experts and the C.B.O. to figure out which tweaks to the various subsidies in the bill would do the most to expand coverage.
Essentially, in the Affordable Care Act debate the Obama administration and Congress rejected a major overhaul that some liberals would have preferred in favor of a gradualist approach that didn’t disrupt existing industries but did result in a large expansion of health insurance availability and federal subsidies.
One hope was that this strategy it would not only help the Affordable Care Act pass in the first place, but would also make it more resilient no matter which direction the political winds might shift. Sure enough, the health insurance industry, hospital and doctors’ groups, and other major interests oppose the Republican plan.
But what happens on the floor of the Senate in the days ahead will determine whether Mr. Obama’s bet was correct. And the nation will, or will not, get to experience a very different philosophy of government’s role in health care.