Thursday, the Senate GOP revealed its long awaited version of the AHCA.  The bill builds on the House’s conservative approach to healthcare while maintaining a federal presence.  Specifically, the bill repeals the Medicaid expansion by 2021 (longer phase-out time), does not allow states to opt out of Obamacare required medical benefits and makes tax credits for premiums be based on age, geography AND income.  It’s a less “mean” bill according to Donald Trump.

The bill is at its core a compromise between conservatives and moderates.  It may or may not pass.  But, regardless, Republicans have staked out a position on healthcare that access to care is not feasible financially.  Rather, access to insurance is!

This has not stopped both those on the Left and Right from claiming we need a “Medicare for all” system, or on the right an “American first healthcare” plan.  Both are plays on the same idea, a single payer system where the government decides what care you get, when and how much it costs.  I bet doctors and hospitals will love it!

Republican and Democratic policy-wonks get that financially such an idea is not feasible.  In California, the cost of a single payer system would eclipse $400 billion.  In Vermont, the former Democratic Governor abandoned the idea because the costs would have jacked up taxes so high the sky really would not be the limit.

This has not stopped the progressive grassroots from crying its needed.  To progressives, money grows on trees and we all know those “greedy” rich people can pay more in taxes.  But, alarmingly, some on the right have begun calling for a single payer system as well.  So far, this has been limited to nationalist and rural blocs of voters that are marginal Republicans at best.  Congressional Republicans don’t even toy with the idea.  But the trend is worrisome both electorally and politically.

The AHCA and the Senate bill, The Better Care Reconciliation Act of 2017, are wildly unpopular.  Most big pieces of legislation are.  But they are also trying to perform a delicate balancing act between having the government be involved in healthcare but also allowing insurance companies (the private market to function) to continue to be involved.  According to some, the bill gets it right where the House version failed.

Ideologically, the bill is moderate in nature.  No, I am sorry, but phasing back Medicaid, and capping its unsustainable growth and halting billions in taxes on pharmaceutical and medical device making companies in which the prices are passed onto the consumer (us) is just common sense.

It also fits with the GOP ideologically.  Right now, the GOP is the party of the middle class, rural areas and the exurbs.  The party is losing ground in urban suburbs (DeKalb, Georgia anybody) but maintaining a strong presence in spread out, suburban areas even with high minority populations (Lancaster, Pennsylvania and Hillsborough, Florida).  This means the GOP has to appease many, many interests.  It’s not pretty to do so but it is necessary.  This bill fits the GOP’s electoral coalition.

The tax credit portion of the bill helps to address rising premiums.  Basing it on age and income as well as geography are musts.  Repealing medical taxes is a way to lower out of pocket costs.  Allowing a phase out of Medicaid Expansion and capping its growth is really the only way to keep the program solvent.

This maintains the GOP’s dominant position in suburban and exurban areas of the country.  Much of the middle class, contrary to popular myth, lives in these exurban and rural areas.  They tend to own their own businesses (not work for massive companies offering excellent benefits) and work in blue-collar professions.

These are the individuals that have been most hurt by the ACA.  Indeed, the ACA is a preview of exactly what a government controlled healthcare system would like, sky-rocketing costs, higher deductibles and crappy plans even with “essential benefits” included.  All a single-payer system would do is take out the middle man, insurance companies.

It’s true Donald Trump ran as an outsider who rejected party orthodoxy.  At times, he sounded like a big government liberal.  At other times he sounded more conservative than Barry Goldwater.  Trump even once said he would “create great healthcare for all.”  I think Hillary said the same thing.

The devil is in the details as always.  There is simply no way America can afford a single payer system.  It is true some polls have shown most Americans support providing care for all.  Note, we already do that through federal laws requiring every individual who walks into an emergency room to be treated regardless of ability to pay.

The ACA was largely passed on the basic premise that employer provided insurance cannot be touched.  It is the biggest distorter of the market but it also provides the best care.  Many individuals in this category already pay the highest taxes and they LIKE their care.  And they VOTE!  As cruel as it may sound, political parties try to win elections not lose them and they chase votes.

Republicans certainly have an incentive to create a system that benefits rural voters.  But, that cannot come at the cost of splitting the party and making it irrelevant.  That is exactly what would happen if the party went as far left as progressives and embraced a single payer system.  Suburban voters would leave the party in droves and marginal rural voters probably would not provide the GOP much award.

Consider this fun fact.  Nancy Pelosi, the very progressive leader of a very progressive party that Republicans love to vilify and who single-highhandedly won them GA-6, said even she does not think the public is ready for a public-option.  In other words, Nancy Pelosi can read the tea leaves.  Polls asking Americans whether they support care for all with no costs associated with it is like asking a kid if they he/she wants ice cream.  Of course they’ll say yes.  Yet, 20 years down the road, when they have diabetes, they might sing a different tune.

Trumpists (as I call them) are blind to these realities.  They rightly point to the plight of rural America (the America I grew up in) and they see a landscape dotted with high uninsured, few jobs and a growing drug epidemic.  Addressing those issues will require some government action and serious investment from the private sector to rectify.  But, simply advocating for a single payer system won’t fix these problems.  Like any system, a single payer system would cut corners and require trade-offs and be as unlikely as the private sector to cover need care for many these individuals.

It’s possible Trump represents the future of the party as do his supporters who advocate for a single payer system.  In this political future, Republicans cease to be small government and engage in a clash of cultures between rural and urban.  To a small degree this is happening.  But, in the hypothetical above, the GOP would be running on a platform that would gain the support of, oh I don’t know, a maximum of forty percent of the country.  Politically, it is not feasible.  And, as a result, they have to do horrid contusions to try to hold their current coalition together.  Democrats had to do the same thing with the ACA and suffered.  Maybe Republicans will.  Maybe they won’t.  But, they will definitely suffer if they embrace a single payer system that is fiscally irresponsible, limits choice, dooms their electoral chances and takes healthcare away from millions of Americans who LIKE it!