The embarrassing failure of the GOP caucus to make good on their six-year pledge to "repeal and replace" the Affordable Care Act is an inflection point in the politics of health care. Democrats should, in the words of an old Chinese adage, "take a warning from the overturned cart ahead" and pursue a robust policy that seizes upon the opportunities of the moment. Many on the left are advocating that the Democrats lift a page from the GOP playbook and begin proposing new legislation right away, in the same way that the Republicans held countless "repeal" votes before there was any hope that they would pass a presidential veto. Though there is provisional wisdom in such strategic thinking, it will only be effective if Democrats are able to take the correct lesson from the GOP's debacle.
The "repeal" dimension of GOP legislation was always going to be much easier than the imperative to "replace" the ACA. Though united in opposition to "Obamacare," when tasked with formulating a policy of their own Republicans were hounded by the same divisions that beset Democrats in 2009 when the ACA was being formulated. Just as some portion of the opposition to the ACA has always been comprised of progressives who do not feel that the bill went far enough in extending coverage and reducing costs, the Republican effort was scuttled by the division between moderate conservatives worried that "Trumpcare" took coverage away from too many people and Freedom Caucus partisans angry that it did not take health insurance away from even more.
The big takeaway from this battle is thus that the bill that can be passed with a unilateral partisan coalition will inevitably be one distorted by ideological wrangling, and therefore unfocused and ineffective as policy. Democrats who are getting ready to propose the institution of a "single payer system" (Medicare for all) are failing to read the lesson of the moment. Such proposals will open up the same kinds of rifts in the Democratic coalition that nearly sank the ACA, and will galvanize energies on the right that have been otherwise neutered by the failure of the "Trumpcare" vote.
Democrats should undertake to move the ball forward from where it sits now, rather than trying to reinvent the field from scratch. The Republicans have declared that the ACA is in peril, and have failed to muster their own coalition to effect a "repeal and replace" rescue. The Democrats should thus respond with a moderate proposal to fix the system as it currently stands. If private insurers are unwilling or unable to offer policies serving the markets created by the ACA exchanges, the federal government should create a "public option" plan to do so.
Ideological opposition on the part of Republicans and conservative Democrats to the creation of a "public option" has been rendered moot by the failure of Trumpcare. If Americans' health care is at stake (and I believe it is), and the GOP cannot summon the political will to act, it naturally falls to the Democrats to step into the breach. Democrats should craft and propose legislation to create a public option immediately and invite their moderate colleagues from across the aisle to join them in a bipartisan initiative to repair the ACA. In the best case scenario the passage of such a law will materially improve the health care of millions of Americans. In the worst case scenario, the proposal of such legislation will put the Trump White House and the GOP on the political defensive for the next four years (and beyond).
Having failed to "repeal and replace" the ACA, the GOP will no doubt try to make the "death spiral" of Obamacare a self-fulfilling prophecy by de-funding key parts of the program and withdrawing institutional support from structures that maintain the working mechanisms of the law. Democrats must move to prevent Republicans from capitalizing on such a strategy by broadcasting that there are reasonable and moderate fixes to the system that could be effected with a modicum of bipartisan compromise. In this way, even if the GOP succeeded in eroding the efficacy of the ACA in the short term, Democrats could run in 2018 and 2020 on the platform of offering the American people a workable alternative rather than more obstruction, dysfunction, and malaise.
The drive for a public option is an imperative that transcends even the urgent chaos of the Trump implosion. Indeed, at this point President Trump is largely irrelevant to Democrats' strategic thinking on this issue (and most others). Even discounting the prospect that Trump may have committed treason and be facing ultimate impeachment, he has so disgraced his office that he can no longer be taken seriously by anyone on any side of the political aisle, in any arena, foreign or domestic. His is now effectively a "zombie presidency," and his political opponents may plan long-term strategy without regard to his preferences or likely actions. If Democrats managed to pass a bipartisan "public option," Trump might veto it in an attempt to pander to his more radical supporters or, conversely, he might sign it into law in a desperate attempt to alleviate the cloud of suspicion and disgrace that is steadily engulfing his administration. The hole into which he has dug himself is so deep that neither stratagem would lift his political fortunes for very long, and in either case the winner in the long term would be the American people.