Healthcare reform is stalled, so says Politifact. Fake news or the truth? Hard to know these days. President Trump and Speaker Ryan both sounded optimistic in recent public appearances. The Tweeter-in-Chief this week tweeted, “Great progress on healthcare. Improvements being made - Republicans coming together!” Maybe so, but remember that every TV news network was optimistic over Hillary Clinton’s landslide victory until about 9 PM on election night.

Is Trump’s enthusiasm part of “The Art of the Deal”? To quote from the book, "I never get too attached to one deal or one approach. For starters, I keep a lot of balls in the air, because most deals fall out, no matter how promising they seem at first." Is the Ryan plan just but one ball floating in the Washington, DC air?

If conservative Republicans in the House and Senate revolt, Ryan’s plan ignominiously dies. What’s next? How about a compromise that just might garner support from all warring factions? There is an old saying, “Compromise is where nobody gets what they want.” But the corollary is that everyone gets something they like out of the deal.

There are five factions in this battle. The Democrats and the political left want government-run healthcare, in the form of universal coverage and/or single-payer. Conservative Republicans want free market reforms without government involvement. The establishments of both parties want only the status quo, slow walking any changes to the point that nothing changes. A majority of Americans believe the federal government should make sure everyone has healthcare coverage. Lastly President Trump has a goal of “insurance for everybody.”

How can such disparate goals be reconciled? The default is Obamacare, which is not working, is unpopular, leaves millions without insurance and is in a financial death spiral. Nothing changes until something changes. What might a compromise deal look like?

In a nutshell, Medicaid-for-all and a parallel free-market driven private insurance industry, free from government interference.

Before I’m called horrible names in the comment section following this article, let me explain.

Medicaid-for-all is catastrophic coverage. Exactly what insurance is designed to protect against. The unexpected and expensive. The car wreck, not the oil change or new wipers. There will be howls of protest over what’s covered and what’s not. The solution is to follow the Oregon Medicaid model. “Rank health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness.” What is at the top of Oregon’s current prioritized list? Maternity and newborn care, substance abuse, sterilization and depression. At the bottom, conditions “with no or minimally effective treatment or no treatment necessary.”

Who makes the rankings? A commission using evidence-based science, a “transparent public process”, and “input from providers and members of the public, including those affected by the conditions.”

Once ranked, a line is drawn through the list based on available funding. Above the line covered, below the line not. Current healthcare spending in the US is $3.2 trillion per year meaning that much could be covered.

Would the Oregon list be the same as a national list? Doubtful. One could certainly argue whether having a baby or being hooked on drugs are catastrophic conditions requiring insurance coverage compared to an accident or cancer, but the process to decide this would be in place.

Those with a vested interest, either as a patient or provider, in their condition being “covered” won’t be happy to land below the cut off line. Let the ranking and cut off line be reviewed and modified twice a year. Make the case that your condition should be covered and maybe it will be in a future ranking.

This should satisfy the political left as it provides their holy grail of universal coverage, and makes concern over preexisiting conditions moot. As well as the majority of Americans who by, “a 76 percent to 24 percent majority also agrees that since most other advanced countries can afford to provide universal health insurance, so could this country.”

The healthcare as a “right versus privilege” is worthy of debate, but politically it’s a nonstarter. Even a populist President Trump called it a right. “I won't let people die in the streets” he declared in one of the early debates.

The other part of the grand compromise is to get government out of the rest of the insurance business. No mandates. No essential benefits. No requirement for individuals to purchase insurance or for employers to provide it. An open market. Purchase what you want and need. Price competition and transparency. Let individuals choose how to spend their money. Like purchasing other types of insurance – auto, home, disability, life, and so on.

Music to the ears of conservative Republicans advocating for free market solutions to healthcare reform.

Many will be happy with their “free” Medicaid. Others will choose to purchase up for coverage of what they deem important. No one will be left uncovered. Everyone gets a seat in the back of the plane. Want more legroom, a free beverage, or a meal, then sit in economy plus or first class and pay the extra fare.

Should private insurance be tax deductible? Some or all of it? Worthy of debate but that’s the fine-tuning. Ditto for work requirements for Medicaid coverage.  Ot wellness incentives. Don’t smoke, exercise and maintain a healthy weight and there can be coverage or financial incentives for both Medicaid or private insurance. Again, that’s in the fine-tuning.

As always, the devil is in the details. This is a 1000-word essay, not a thousand plus page legislative bill. Meaning there will be plenty of “what about this or that?” The idea still holds. A compromise. Disliked by all but perhaps acceptable to all as well.

Remember the words of the Rolling Stones. “You can't always get what you want. But if you try sometimes well you might find you get what you need.”

Brian C Joondeph, MD, MPS, a Denver based physician and writer. Follow him on Facebook  and Twitter.