Thus far, the Republican war against health care reform has been one long, blaring cry to repeal the federal law. Given just how unlikely this outcome would be under the current administration, the GOP's strategy has largely come across as political posturing meant to undermine the Democrats rather than offer any constructive alternatives or changes to the Affordable Care Act.
That was until Thursday, when Sen. Scott Brown (R-Mass.) decided to break away from his party's all-or-nothing call for repeal, proposing a reform that could actually be an improvement on the federal law. Brown has teamed up with Democrat Sen. Ron Wyden (D-Ore.) to introduce legislation that would allow states to opt out of the individual mandate to purchase health insurance more quickly. Under federal health care reform, states can appeal to the federal government for mandate waivers beginning in 2017 if they propose an acceptable alternative. Brown and Wyden want to push the start date to 2014, so that states don't have to go through the motions of complying with the federal law if they have an alternative plan in the works.
Within the Affordable Care Act itself, there is already a way for states to opt out of the law—one that doesn't require suing the federal government or repealing the entire thing. Wyden had pushed to insert this provision in the original bill—as Oregon had already begun experimenting with alternatives to federal Medicaid—along with Sen. Bernie Sanders (I-Vt.), who supports bringing a single-payer system to Vermont. But the state waivers don't just support liberal alternatives: any state can apply to opt out of the federal law, provided that they meet certain criteria. Ezra Klein explains: "If a state can think of a plan that covers as many people, with as comprehensive insurance, at as low a cost, without adding to the deficit, the state can get the money the federal government would’ve given it for health-care reform but be freed from the individual mandate, the exchanges, the insurance requirements, the subsidy scheme and pretty much everything else in the bill."
This all makes sense to me: conservative legislators and states that have been complaining about oppressive federal mandates actually have the opportunity to put their own ideas to the test, and the Brown-Wyden bill will make it even easier for them to do so. Yes, there are certain things that are non-negotiable: states must provide coverage that's as comprehensive as the federal law, for instance, which will force conservative-leaning states that have failed to insure many low-income residents to expand access. For states that have been complaining about a "one-size-fits all health care plan," the waiver "provides flexibility and allows states like Massachusetts to opt out of portions of the health care law," as Brown himself says.
Health reform advocates could use the waiver to press opponents to explain exactly how they'd do a better job: those who oppose the law would have to articulate exactly what their state-based, non-federal alternative would look like. Texas Governor Rick Perry, for instance, recently threatened to drop out of the federal Medicaid program altogether, claiming that states could act as "laboratories of innovation" to devise a different plan for insuring the poor. The Brown-Wyden bill will make it even easier for states to step in if they can indeed offer better ideas and not just incendiary rhetoric. And legislators like Perry could find themselves under increasing pressure to put up or shut up.
Moreover, Brown's move is an encouraging sign that not all Republicans are wiling to go along with the GOP's just say no approach to governing, and his bipartisan proposal could draw other moderate Republicans out of the woodwork. Sen. Bob Bennett (R-Utah) was primaried out of office precisely because he committed the heresy of collaborating with Wyden on health care. And Maine's Olympia Snowe—who's already facing a GOP primary challenger—has shown signs of shifting rightward, signing onto a brief supporting the states' lawsuit against health care reform after she'd worked for months on the bill. Brown had already broken with his party on multiple high-profile occasions, and his latest move suggests that he's willing to carry the torch into the next Congress.