Republicans in Congress are struggling to come up with a way to fix the Affordable Care Act (ACA, colloquially referred to as ‘ObamaCare’). After seven years of condemning it, and nearly as many passing symbolic bills to repeal it, they are still stumped about how to, you know, do something about it . . . even with the presidency and majorities in both houses of Congress.

This is why the Republican Party is sometimes called the ‘stupid party.’

Although the ACA has helped some Americans on the lower rungs of the economic ladder to obtain affordable health insurance, thanks to large government subsidies, those of us who were already insured and don’t qualify for those subsidies have seen our premiums skyrocket along with our deductibles. Although healthcare prices were outpacing inflation before the ACA, the law has likely made it worse . . . and it certainly didn’t reduce prices, which was one of the promises. Don’t forget, ‘affordable’ is in the name.

Part of why my insurance rates keep skyrocketing is that the insurers have to get the people in the system to pay for the people who are gaming it or getting freebies. Nothing comes for free. For every success story about somebody with preexisting conditions getting covered, or about somebody who doesn’t have to worry about lifetime caps anymore, there are a hundred other people—like me—quietly trying to cope with paying much higher premiums for worse insurance plans than we had in 2008.

Many of us who have been harmed by the ACA want to see it repealed and replaced. Doing this way back in the early days of the ACA would have been a good strategy for the Democrats, but they instead doubled-down on the mess. That was not smart, though, admittedly, it might have been smarter than the Republican strategy of waving their arms around for seven years without bothering to come up with a better plan.

The most infuriating thing about this is that coming up with a conservative reform of our health care system isn’t difficult. I mean, the federal government has no authority to regulate healthcare at all except where it intersects with interstate commerce, so all the plan has to do is set some general rules for health care across state lines, and a mechanism for phasing out the federal health care infrastructure and turning it over to the states. I could write up a solid framework for federal health care reform in about 1,200 words . . . that’s about two pages. After translating my framework into the necessary legalese, I bet it would still be less than ten pages long.

The Democrats gave us a 2,300 page monstrosity, which we passed, but we’re still trying to decipher what was in it.

Republicans have also given us bills that are hundreds of pages long, even though they rely on much of the ACA staying on the books. (The Republican bills proposed so far are not actually ‘repeal and replace’ bills; they are ‘keep ACA and tweak it around the edges’ bills.)

And nobody has yet proposed the kind of simple, conservative health care reform plan that I could support.

Democrats won’t propose such a bill because it would reduce, rather than increase, the federal government’s power and involvement in people’s lives. Republicans haven’t proposed such a thing because many of the Republicans in power today aren’t actually conservatives, and either don’t believe that a conservative plan would work, or are unwilling to take the political risk of supporting one. President Donald Trump (R), for example, is a center-left, big-government president in all but temperament . . . which is why, despite his ‘repeal and replace’ Twitter rhetoric, he is actually supporting bills to tweak the ACA without any real reform.

So the Republican Party is shooting itself in the foot. If they don’t pass something to fix the ACA, their middle-class base will turn against them. If they do, and it’s just a few tepid adjustments to the ACA rather than any real improvement, their middle-class base is only slightly less likely to turn against them. Nobody seems to have the guts to write a good bill that might actually gain the support of the nation’s conservatives . . . a bill that, if it works as well as I am sure it would, might even gain support from the nation’s progressives (if not initially, then over time).

The parallels to what the Democrats did in 2008 and 2009 are striking. They forced through a bad bill with the barest minimum of support because they thought their base would be impressed, but in reality they set themselves up for a political disaster in 2010, when Republicans gained a record number of congressional seats. The Republicans are now attempting to force through their own bad bills with the barest minimum of support . . . and whether they succeed or fail, they are likely to fare in the 2018 congressional elections as poorly as Democrats did in 2010.

So, dearest Republicans, I suggest that you go back to the drawing board, and do it quickly. Get a good bill on the floor within the next month, and get it passed. Make it a solid, conservative bill that operates within the confines of the U.S. Constitution. Try hard to get some Democratic support if you can (though in this political climate I doubt if any Democrats would vote for a bill in favor of puppies if it had been proposed by Republicans). You must at least make sure it has the support of your own party. If you keep pushing forward with the crap you’ve put together so far, be ready for your own 2010-style ‘shellacking’ in November of 2018.

Remember how I said I could write up a solid framework in less than 1,200 words? Well I did. It’s not perfect; I came up with it in an hour or two. But it’s still better than the ACA. And it’s better than the various Republican bills proposed so far . . . because this bill is built on the basic conservative principles of fairness and federalism. And as an added bonus, it even offers a proposed fix for the badly broken veterans’ health system.

Don’t tune out just yet, progressives. I even included a provision making it clear that states are welcome to set up ‘single payer’ systems if they want, as long as they deal fairly with the other states. Unlike most progressives, we conservatives and federalists don’t assume that one size fits all. The deep blue states are welcome to set up socialized, government-centric systems if they want. And the deep red states are free to set up radically free market systems. And the states in the middle are free to develop hybrids in-between. Let’s try everything and see what works. Over time, the bad systems will fall apart and those states will switch to the good ones.

There is no reason to impose any one solution on all the people of all fifty states as if they are one homogeneous mass . . . because they aren’t. The state governments should step up and do their jobs and stop expecting Washington to do it for them.

A Reform Bill Framework

  1. All federal laws and regulations pertaining to the health care industry, excluding those pertaining to Medicare, Medicaid, and the military health care system, are repealed.
  2. Any medical insurance company licensed to operate in any state shall be permitted, without restriction, to offer its products to citizens and residents of other states. Any insurer that chooses to do so, having engaged in interstate commerce, shall be subject to the following. The states are also encouraged to enact similar restrictions on insurers that are not engaged in interstate commerce.
    1. Individual insurance policies and premiums shall be set uniformly for all customers on the basis of average risks and costs across the individual customer pool. These polices shall be made available to all individuals without regard to their individual attributes or conditions.
    2. Family insurance policies and premiums shall be set uniformly for all families of equal number on the basis of average risks and costs across the family customer pool, however the premiums for families may not be higher than the premium for individual policies covering the same number of people. These policies shall be made available to all families without regard to the individual conditions or attributes of any members of the family.
    3. Customers shall have the right to seek medical care from any provider licensed in the state in which it operates, with the costs of said care to be paid by the insurer, less any deductibles and patient portions agreed to under the terms of the policy.
    4. No insurer may charge any customer more than 10% in additional out-of-pocket costs for care given by a provider who has been deemed by the insurer to be ‘out of network’ versus the cost for the same care provided ‘in network.’
    5. Upon issuing a policy to any individual or family which, immediately prior to obtaining a policy, shall have had a break in health insurance coverage longer than 120 days, the customer shall have the following options:
      1. Voluntarily exclude preexisting conditions from coverage for a period of one year.
      2. Or, pay a preexisting condition surcharge, which shall be equal to no more than 50% of the cost of an individual insurance plan, to cover those conditions until the conclusion of the first year.
    6. Insurers may, but shall not be required to, provide coverage for elective or medically unnecessary medicines and procedures.
    7. No insurer may refuse to offer insurance to a customer, nor may an insurer discontinue insurance coverage for a customer, due to any medical condition. Nor may an insurer set any lifetime or annual coverage limits. Nor may any insurer refuse to cover any condition or charge a surcharge for any condition, except as provided by this bill.
    8. Insurers subject to this section must accept all employer and government insurance vouchers as provided by this bill.
  3. Any medical facility or provider that accepts payment from insurers operating across state lines, thereby having engaged in interstate commerce, shall be subject to the following. States are also encouraged to enact similar restrictions for providers not engaged in interstate commerce.
    1. All services and procedures shall be priced uniformly for all customers, whether insured or uninsured, except as provided by this section.
    2. A facility or provider may enter into contracts with one or more insurers, which may then deem that facility or provider to be ‘in network,’ but the total price of all services and procedures for ‘out of network’ or uninsured customers shall be set no more than 10% higher than those for ‘in network’ customers.
  4. Any employer that operates across state lines shall provide all of its employees with a health care voucher, which shall be usable toward the cost of any licensed individual or family health insurance plan. No such employer shall offer predetermined health care plans as a benefit of employment in lieu of this voucher. States are also encouraged to enact similar restrictions for employers not engaged in interstate commerce.
    1. For employees working at least 35 hours per week, the amount of this voucher shall be no less than 60% of the average cost of an individual, full-coverage health insurance plan.
    2. For employees working less than 35 hours per week, the amount of this voucher shall be equal to the amount provided to full time employees, but prorated to the number of hours worked per week as a proportion of 35.
    3. This voucher shall not be provided to employees residing in a state that has adopted a ‘single payer’ health care system.
  5. Via existing state and federal welfare programs, a government health insurance voucher equal to the average cost of an individual, full-coverage health insurance plan shall be provided to all individuals and families below the poverty line. This shall be initially funded by the federal money previously intended for funding the ACA.
    1. This voucher shall be prorated as income rises above the poverty line, by a formula to be developed by the Department of Health and Human Services, so as to discourage individuals and families from remaining below the poverty line to maintain voucher benefits.
    2. Over a period of ten years, all federal welfare programs, including this voucher program, and also including the federal insurance exchange (HealthCare.gov), Medicare, and Medicaid, shall be transferred to programs managed and funded by the several states under their own duly-enacted laws and policies.
    3. This voucher shall not be provided to persons residing in a state that has adopted a ‘single payer’ health care system.
  6. Per the Tenth Amendment to the U.S. Constitution, the several states are responsible for the regulation of their health care systems. If any of the several states implement a ‘single payer’ or ‘socialized’ health care system for its citizens, it shall be subject to the following restrictions per the ‘interstate commerce’ and ‘full faith and credit’ clauses.
    1. Any state implementing a ‘single payer’ system shall establish a state-owned and state-funded insurance provider for the purposes of covering all medical costs incurred by its citizens while traveling overseas or to states with market-based insurance systems.
    2. Any state implementing a ‘single payer’ system shall provide care to any persons within its borders, but may charge a fee, equal to the cost of providing that care, to any nonresident. The nonresident shall then remit payment either directly or via their private, state, or national insurer.
  7. The veterans’ health care system, its medical facilities, and its employees, along with all funds budgeted for its operation, shall be transferred to the Department of Defense and integrated into the military health care system.
    1. All veterans shall have access to this combined system for service-related medical treatment, and shall be treated on an equal basis with those currently serving in the armed forces.
    2. Those currently serving in the armed forces may be prioritized for treatment ahead of veterans, but only to the least extent necessary to maintain full combat readiness, only during times of active war or conflict, and only by the order of the Secretary of Defense.