Bipartisan Health Reform? Obamacare in the States

Few laws have provoked as much furor as the Affordable Care Act (ACA). Yet, even as the conflict rages, a compromise between Democrats and Republicans may be emerging on the ground. Beyond the partisan Washington histrionics, a new health care regime –call it the mixed or purple ACA—might just be rising.

The ACA itself has two large programmatic components.  One is a classical Republican idea: health insurance marketplaces. The other expands Medicaid. The red half of the law tries to tap the magic of market capitalism. Republicans have long tried to inject market competition into both new and existing health programs. Ironically, Democrats have now lashed their political fate to an idea that liberals have long disparaged as unjust, unfair, and too complicated. On the blue side, the law expands Medicaid – a classic government program from the halcyon days of the Great Society. The ACA sponsored the largest expansion of health care benefits to poor Americans in history.

The Supreme Court essentially upheld the red part of the ACA and turned the blue part over to state politics. The general expectation was simple: Democratic politicians will expand Medicaid, Republicans will oppose. In the states, however, an unanticipated result may be emerging.

Republicans and Democrats appear to be fumbling toward a bargain. Democrats get their Medicaid expansion. Republicans privatize the program by putting new –and, eventually, all—beneficiaries into the exchanges. Some conservatives have begun to suggest expanding the concept even further – perhaps even to Medicare. It may be that the moderates in both parties have a path to implementing –and even expanding—the ACA. The law’s framer’s quite unwittingly facilitated local health care bargains that, in effect, tie Democratic goals (expand benefits) to Republican means (market competition).