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How moderate Republicans disappeared from health policy

House Speaker Paul Ryan
House Speaker Paul Ryan during the 2017 health care debate. (Photo:Win McNamee/Getty Images)

The past decade's health care wars have pushed Republicans to the right, squeezing out moderates who see some acceptable role for the federal government.

Why it matters: More health care wars are coming, and the parties are only moving further away from each other. By demonizing so many policy ideas as "Obamacare-lite," the GOP has left itself with fewer policy alternatives and less room to compromise.

“The far right has kind of sucked all the oxygen out of the room. Right now, it does seem like it’s hard for more moderate policy ideas to really get a lot of traction."
— Ben Ippolito of the American Enterprise Institute

The big picture: The Affordable Care Act "changed radically the nature of the way Republicans view health care," said Rodney Whitlock, a lobbyist and former aide to Sen. Chuck Grassley.

Before the ACA, there were plenty of conservative arguments for a stronger federal role in the health care system. Many of those more moderate GOP ideas made it into the ACA, mixed in with other traditionally Democratic policies.

  • "The infrastructure of the Affordable Care Act was a hell of a lot closer to Romneycare than a single payer system," Whitlock said.

Now that the party has bitterly opposed the ACA for nearly a decade, it's difficult to propose ideas that bear any resemblance to it.

  • “After watching 2017 unfold and the occasions of which 'Obamacare-lite' got thrown out at some folks, for Republicans, it’s going to be hard for them to look at anything other than basically ... confederal solutions, where they say its important that we send solutions out to the states, and we step back," Whitlock said.

“It’s hard enough to make policy as it is. It’s nearly impossible if you don’t give yourself any options," Ippolito told me. "They are giving themselves an awful lot of constraints to deal with.”

  • "If you're not even willing to concede that some version of regulated competition is a plausible strategy for this market, then realistically, what are you going to argue down the road?" Ippolito asked. "We’re going to take the stand of [Sen.] Rand Paul? His idea of health care is the only one we’re allowed to have now?"

Last year's repeal-and-replace effort also reinforced the popularity of several ACA regulations, like requiring insurers to cover pre-existing conditions. Yet those rules are a target for the right flank of the party, because they increase premiums.

What's next: The health care system's problems are not solving themselves. And while Democrats solidify their response — some form of expanded government coverage — many elected Republicans are trying to avoid the topic.

  • Off the Hill, there are plenty of center-right policy wonks cranking out ideas, like increasing price transparency to foster market competition and automatically enrolling people in private health insurance.
  • But if moderates in both parties are losing power, "the chances of serious bipartisan discussions on health care are basically nil," Kaiser's Larry Levitt told me.

"Obamacare left such a sour taste in our mouth," Sen. Mike Rounds told me. "So anything that looks like that, immediately people are suspect," he continued. "On the other side, there’s a lot of us that really do believe that if you allow for competition on the marketplace and you allow for innovation, and you make it a fair playing field, you could come up with some really good health care policy."