On Monday, President Barack Obama met with the nation's governors and announced his support for the first major amendment to the Affordable Care Act since the bill was signed last March. The proposal, crafted by Democratic Sen. Ron Wyden of Oregon and Republican Sen. Scott Brown of Massachusetts, would allow states to opt out of key planks of the health-care bill provided they met the administration's benchmarks.
Given the political heat Obama has taken from Republican governors over health-care reform, you could think that this proposal represents a small step toward capitulation. But that would be wrong. In truth, this measure is a major first step toward securing the Affordable Care Act's short-term viability.
First, the details: Under the original bill, states could not receive waivers until 2017, three years after the initial implementation date. The Wyden-Brown amendment would shorten the wait time to zero and allow states to apply for waivers as soon as implementation began, in 2014. The waivers would apply to any part of the bill -- including the individual mandate -- as long as states aren't shirking the requirements set by the Affordable Care Act. As President Obama said in his announcement, "If your state can create a plan that covers as many people as affordably and comprehensively as the [health-care law] does -- without increasing the deficit -- you can implement that plan."
With waivers, states could tailor their plans to suit their constituencies. In Vermont, Democratic lawmakers are exploring the idea of using waivers to create a single-payer system for health-care coverage -- similar to what exists in Canada -- and in Massachusetts, lawmakers are considering waivers as a way to maintain and improve their current system of universal coverage without the burden of additional federal mandates.
In theory, Republicans should love early waivers. For reform-minded conservatives like Indiana Gov. Mitch Daniels, who recently penned a Wall Street Journal op-ed asking for greater flexibility, early waivers would provide an opportunity to implement their own variations on health-care reform, separate from the structures devised by the administration. Few countries have tried a system of health-savings accounts and universal catastrophic insurance, but if conservatives believe it can solve the problem of shoddy coverage and high costs, then they would be able to try it.
Of course, this hasn't stopped Republicans from opposing the measure. After the meeting, Texas Gov. Rick Perry, chairman of the Republican Governors Association, said that the "waiver doesn't really address the structural flaw we are all facing now." Likewise, Nikki Haley, South Carolina's newly minted Republican governor, said that the administration would "do us a favor if they let us opt out of the entire law."
Congressional Republicans have been similarly scornful, which makes sense given their "repeal and replace" strategy. As Orrin Hatch, senior Republican on the Senate Finance Committee, told the Washington Times, "Despite the administration's claims, state flexibility under Obamacare does not exist -- not now, not five years from now, not 10 years from now." Even the measure's co-sponsor, Scott Brown, felt the need to reiterate his opposition to the health-care-reform law in its entirety: "[Senator Brown] strongly opposes the federal health care law, and believes states should have the ability to implement their own plans that provide quality care for all their citizens," his spokesman said in a statement.
Republican opposition all but condemns the proposal to legislative death. That said, the politics of this will almost certainly play well for President Obama. For starters, GOP opposition allows him to play his favored role: the reasonable moderate. With his support for flexibility on the table, Obama can easily say, "We tried to be open, but they wouldn't have it." This is bound to sit well with a public that craves the appearance of bipartisanship; in a recent poll conducted by the Pew Research Center, 61 percent of Americans say they want GOP leaders to work with Obama, while 65 percent say they want Obama to work with Republicans.
More important, this could prove to be a political winner for the Affordable Care Act itself. Given the current trajectory of public opinion, Republicans will eventually have to deal with a public that is broadly supportive of the Affordable Care Act. Flexibility -- and the ability to tailor reforms -- creates the space for Republicans to step away from rigid opposition, maintaining conservative credibility while signing on to the broader project of health-care reform.
Put another way, federal programs are most durable when they have significant support from members of the conservative party. Social Security and Medicare survived, in part, because Republicans grew to support the programs for political and ideological reasons. On the other hand, more politically contentious programs, like Medicaid or welfare, have always faced cuts or outright attempts at elimination. The further the ACA moves away from political controversy, the closer it is to long-term political viability.
