By Dr. John C. Goodman

Originally posted at Forbes, May 2017.

It’s a flawed program. Everybody knows it. Premiums are too high. Deductibles are too high. Doctor and hospital networks are too narrow. Millions are gaming the system by staying uninsured until they get sick or by stopping their premium payments in the ninth month – knowing that they won’t have to pay medical bills for the rest of the year. Insurers are leaving in droves. One third of the counties have only one insurer left. After Blue Cross leaves, in most cases there will be none.

So, why can’t Republicans do anything about it?

For the answer to that question you have to delve into the conservative mind.

For most of the 20th century, Democrats were on offense. Republicans were on defense. Democrats, or shall we say liberals, were dedicated to reform. Republicans, at least conservative Republicans, were committed to defending the status quo. Conservatives honed their skills in filibustering, tabling, offering unfriendly amendments and in other ways stopping liberals from doing whatever it was they wanted to do. They didn’t develop the skills to reform anything. They didn’t need them.

Remember Bill Buckley’s definition of a conservative? “It’s someone standing athwart history yelling stop.”

Then came Ronald Reagan. Reagan Republicanism is associated in the public mind with change – tax reform, deregulation, etc. It was an era of conservative change worldwide. In the latter two decades of the 20^th century, Margaret Thatcher pioneered the techniques of privatization in Britain. More than 30 countries privatized their social security systems to one degree or another. Many countries – including some formerly communist eastern European countries adopted a flat tax. Sweden implemented school vouchers for public school children.

You could summarize all this by saying that a huge role reversal took place. Reform came from the right. Resistance came from the left. As with the rest of the world, so it was in the United States.

But not so fast.

It may be helpful to remember that the deregulation of our major regulatory agencies began under Jimmy Carter and was championed by Sen. Teddy Kennedy. Parallel to the Kemp-Roth Republican tax reform was the Bradley-Gephardt Democratic version, dedicated to the same goal: broadening the base and lowering the rates. And welfare reform? It was one of the key planks in Bill Clinton’s 1992 campaign for the presidency.

Yes, Reagan was a reformer. So was Jack Kemp. But they’re no longer with us. And the typical Republican in Congress today doesn’t have very much in common with either of them.

Suppose the shoe were on the other foot. Imagine that the failed and failing health reform was a Republican rather than a Democratic fiasco. What would Democrats have been doing for the past seven years? If they controlled the committees, they would have held a hearing virtually every week. They would have paraded the victims of Republican health reform before the public eye. They would have held briefings, conferences and other public events to highlight the harms and how they would change them. They would have sought solutions from every corner of their party. They would have tried to forge opposition consensus. They would have done …. well, all the things the Republicans didn’t do.

In addition to all that, here are five big Republican misses .

No vision. “Repeal Obamacare” is not a vision. Yet almost the entirety of the Republican conversation about health care has been a debate over how much or how little of it is going to be repealed. If you are chronically ill and in need of continuing medical care, what’s going to happen to you? Comb through speech after speech on the GOP side of the aisle and I bet you won’t find out.

No Collaboration. Designing a reform behind closed doors; announcing to the world “this is all you’re going to get – take it or leave it”; signaling you don’t plan on getting a single Democratic vote; failing to get input from the moderates and the conservatives or any other Republican faction that really mattered; failing to make the special interests groups part of the process – these are not the ways House Speakers in the past got legislation passed. I don’t think a single interest group supported the Ryan health reform. Even employers were against it. And remember, Ryan was offering all these folks tax repeal, totaling close to $1 trillion. What more can I say?

No victims. If Congress passes a Republican replacement plan, who is it going to help?  When the Democrats passed Obamacare, they left no doubt about the target audience: people with pre-existing conditions, including those in the group market thinking about a layoff or early retirement. Who are the Republicans trying to help? That’s anybody’s guess.

No message. In the individual market, there have been two principal classes of victims: (a) people who are sick and who face high deductibles and narrow networks that omit the best doctors and the best facilities for their conditions, and (b) people who are healthy and who are paying high premiums – in some cases, two, three or four times what they previously paid. Republicans have not explained to either group how their problems are going to be solved.

No thought. Under a Republican replacement plan, what will happen to the 30 million people who are expected to remain uninsured under Obamacare? If the GOP plan would add even more to that number (24 million?) what will happen to them? How will the safety net hospitals get funded? What happens when low-wage employees getting health insurance at work receive a federal tax subsidy well below the subsidy received by those with similar incomes in the individual market? What happens when higher-income people in the individual market receive a subsidy well below the subsidy those with similar incomes receive at work? If there is a risk pool, how will it work? So far, the answer is: who knows?

Don’t voters deserve at least a PowerPoint presentation where all this is spelled out? Small wonder that public approval for the Republican efforts so far stands at 17 percent.

This article was originally published at Forbes on May 1, 2017. (http://bit.ly/2qTHWtX)