Republicans, with significant effort, passed Healthcare Reform out of the House.  Now, the effort is stalled in the Senate with both conservatives and moderates balking at various elements of the bill.

In a perfect world, all sides would get what they want in the bill.  They won’t.  Healthcare policy always involves winners and losers.  It is the dynamic Democrats pretended did not exist in 2009 and 2010 and they paid the political price.  Republicans should not be so foolish.

Republicans certainly should not be so foolish as to repeal and replace “later.”  Advocates argue this strategy is smart, especially if repeal is delayed a year.  But insurers will not wait a year.  Democrats will only be to happy to watch the public punish the GOP next year.  Iowa, which does not have a single insurer on its exchanges, may become the norm.

Still, the contours of a deal on healthcare are clear.  It will involve concessions on all sides and for Trump to sell the deal.  So, first-off, Trump should push McConnell and budge hardliners to accept the Medicaid plan negotiated plan between the House and his office.  House Republicans agreed to cap Medicaid growth rates to the cost of medical inflation while the Senate caps it at an even lower rate.  The Senate plan is too stringent and is pushing away centrist Senators.  The Senate should add in the House language and remove the original language from Senator Pat Toomey (PA).  The House’s reforms are still the most wide scale reform of Medicaid since 1990.

The Senate bill has been described as “mean” by President Trump.  So, he should back what he means with action.  More specifically, he should side with GOP Governors in expansion states who say they need time and flexibility to cover the poorest Americans.  Obamacare was a picture perfect example of the government using a carrot and stick approach to get states to do what they wanted.  The carrot was providing an initial 100 percent match to states to expand Medicaid while eventually never dropping below 90 percent.  The stick was forcing states to expand Medicaid to continue receiving current Medicaid funds (the SCOTUS killed that plan).

Expansion allowed able-bodied men and women without kids to be covered for the first time and provided more of a match then traditional Medicaid.  The idea was to lure states in and hope the projected savings would offset increased costs.  They did not.  Now the system is unsustainable.  Republican Governors want seven years to work with HHS and the administration to even out Medicaid cost shares so that able bodied men and women are not matched at a higher rate than families with kids.  Additionally, it gives Governors and states time to develop budgetary strategies to handle the change.  These are valid concerns and they should be included in the final package.

Third, Trump should push for McConnell to include in the bill funding for the opioid crisis.  McConnell would probably acquiesce easily on this point and Republicans should be working to ensure people who need treatment and support can get help and find work without being trapped in Medicaid.

Forth, the GOP should easily pass the “Consumer Freedom Amendment” proposed by Sens. Ted Cruz (R-Tex.) and Mike Lee (R-Utah).  This would allow insurers to sell health plans that don’t comply with all Obamacare regulations, so long as they sell at least one plan that does. Sen. Bill Cassidy (R-La.), who happens to be a doctor, has a way to make sure that risk pools for people with preexisting conditions work under the Cruz approach. Do it.

Lastly, Republican should not nix the investment tax on individuals earning $200K and couples earning $250K to cover the costs of reform.  Many of these households already receive generous employer provided insurance plans and would likely not be adversely impacted by keeping the tax.  They likely care far more about tax reform which WOULD impact them.

Passing such a bill, sending it to the House, which should also sign it will allow the GOP to campaign on repealing the ACA, keeping its promise to lower premiums, and protect lower income Americans and those with pre-existing conditions.  Democrats would be hard pressed to argue the bill does not help the most vulnerable when Governors across the nation are stressing it does.  Likewise, Trump should be selling the plan on its merits and pointing out all the positives of the bill.

The only question is whether Republicans want to win or not?  I am betting they do.