Robert Laszewski–an astute observer of health care policy and no fan of ObamaCare–had a post on Monday about the recently proposed Republican alternative to the Affordable Care Act. He writes:
The problem for Republicans is that they have such a visceral response to the term “Obamacare” that they just can’t bring themselves to fix it. The notion that Obamacare might be fixed and allowed to continue as part of an Obama legacy and as a Democratic accomplishment is something they can’t get past.
Bingo. Since November 4, 2008, about the only thing that has united Republicans, aside from cutting taxes for the wealthiest Americans, has been their unrelenting desire to deny President Obama any accomplishment, regardless of the consequences. And exhibit number one is the Affordable Care Act.
This strategy of cynical obstruction originated as early as the transition period leading up to Obama’s inauguration on January 20, 2009. In Michael Grunwald’s book, The New New Deal, he quotes Joe Biden as saying, “I spoke to seven different Republican Senators, who said, `Joe, I’m not going to be able to help you on anything.” “The way it was characterized to me was: `For the next two years, we can’t let you succeed in anything. That’s our ticket to coming back.’” As former senator George Voinovich confirmed to Grunwald, “If [Obama] was for it, we had to be against it. [Mitch McConnell] wanted everyone to hold the fort. All he cared about was making sure Obama could never have a clean victory.”
Then there was the Republican strategy session on the night of the inauguration, in which they agreed to “show united and unyielding opposition to the president’s economic policies,” as well as other objectives designed simply to hurt the president and congressional Democrats. And of course, shortly before 2010 mid-term elections, Mitch McConnell famously stated, “The single most important thing we want to achieve is for President Obama to be a one-term president.”
So it’s been orchestrated obstruction, solely for political gain. There has never been a spirit of cooperation and compromise among Republicans since President Obama was elected. Nevertheless, a stimulus plan was enacted. Financial reforms were signed into law. Health care reform did happen. And President Obama was re-elected to a second term in 2012. What did Republicans get in exchange? The lowest approval ratings in the history of such ratings, and the indignity of repudiating the very things they once supported. Oh, they did win back the House in 2010, which lead to such smart ideas as repeatedly holding the American debt hostage to one silly demand after another. On the whole, it’s been a dismal performance.
My favorite Republican throughout this process was Senator Chuck Grassley, whose hypocrisy was stunningly comical. A member of the “gang of six” that was supposedly negotiating a bi-partisan health care solution in the summer of 2009, he was an unequivocal supporter of the individual mandate going all the way back to legislation he co-sponsored in the 1990s. (Yes, it was a Republican idea in the first place.) Then in September he suddenly disavowed his own long-held positions, completely undermining his own credibility.
All of this brings us to Robert Laszewski’s article about the Republicans’ current predicament vis-a-vie health care. “My sense is that most independent voters––the ones that matter in an election-year––don’t want Obamacare repealed; they want it fixed.”
Bingo again. But as Laszewski writes, Republicans have driven themselves into a ditch because of their unwavering insistence on repealing ObamaCare and starting over.
There is a problem with that strategy. Have you heard the one about, “If you like your health insurance you can keep it?”
It is now 2014. The Affordable Care Act is law. The Republican alternative would mean taking lots of things away the Democrats will quickly pounce on:
Medicaid Expansion – The Republican alternative would “not expand” Medicaid––presumably rolling back the Medicaid expansion in each of the 24 states that have expanded it. By year-end, millions of Americans will have gained coverage. Who wants to tell these people now on Medicaid the Republican alternative only contemplates covering pregnant women, low-income children, and low-income families at the old levels? Twenty-four states that would see benefit cuts equates to 48 U.S. Senators.
Insurance Subsidies – The Republican alternative would offer health insurance premium subsidies for people up to 300% of the poverty level. Far fewer people than expected are buying Obamacare but that number will be well into the millions before long. Obamacare offers subsidies up to 400% of the poverty level meaning that lots of people would lose their subsidies––and they would be the voters who are solidly middle-class.
The Tax Exclusion for Employer-Based Health Insurance – There is no health insurance policy so sacred in America as the one a worker gets from their employer. The Republican alternative would cap the tax exclusion, currently at 100% of whatever the employer gives the worker and their family for health insurance, at 65% of the cost of the “average” cost of a policy. Democrats will quickly jump on this as a huge middle class tax increase and an attempt to undermine employer-based health insurance.
Lower Premiums for Older People – A controversial part of Obamacare was its requirement that older people can’t be charged more than three times the premium of the youngest. That contributed to the rate shock that hit many people in the small group and individual market when Obamacare policies had to comply. Republicans would take people through the same political nightmare once again but in reverse this time. Their plan would cap rating differences at 5:1, thereby forcing older peoples’ premiums up, and younger peoples’ premiums down. Older people tend to vote more often. Ironically, they have also been the ones who so far have more often bought an Obamacare compliant policy.
The Prohibition of Pre-Existing Condition Provisions – As of January 1, 2014, there is no such thing in America any longer. But Republicans would bring the provision back if people did not maintain continuous coverage. That sounds fair. But what happens when someone is forced to drop their expensive coverage when they lose their job for a few months and the Republican tax credits don’t give them enough help maintaining it? Democrats will be able to think of lots of scenarios where a family playing by the rules has no choice but to drop coverage and face pre-existing condition provisions once again.
Each of these Republican proposals is credible and constructive and should be part of any discussion over how to move forward with health insurance reform.
Look, no one thinks the Affordable Care Act was perfect. It was an historic step toward health care reform, but any reform of this magnitude consists of trade-offs and potential missteps. Eventually, improvements are going to be made and trade-offs tweaked. But Republicans have painted themselves into a corner. For years, they’ve insisted that nothing will do other than a full repeal of ObamaCare and a return to the previous status quo. That becomes more infeasible with every passing day. Eventually they’ll be seen as the ones proposing radical disruption as opposed to the Democrats proposing sensible improvements.
Republicans will insist that ObamaCare can’t be fixed and we must start over, “but tell that to the older people who Democrats will be quick to remind will be paying more, the middle class people who would get their health insurance subsidies cut, and the 160 million people who get their health insurance––which they really like––through employer-based plans and will see their taxes go up.”
Ah, the irony. After years of being the party entirely dedicated to obstructing, it will be fascinating to see how Republicans become the party of doing. That is, if they can muster the courage.
Jonathan Chait has a similar take in his column today. His conclusion:
Once it was no longer useful as a weapon to stop universal health insurance, the Republican health-care plan had to be abandoned. This was the fate of every Republican health-care plan, a durable pattern I call the Heritage Uncertainty Principle. Republican health-care proposals reside in a state of quasi-existence, and any attempt to summon them into political reality will cause them to disappear. Their purpose is to refute the accusation that Republicans lack a health-care plan. The elusive quasi-plan allows them to claim all the potential benefits of health-care reform without having to defend any drawbacks. The game offers Republicans advantages they are unlikely to forfeit for the rest of the Obama era.
The rapidly approaching dilemma for Republicans is that the endgame of preserving the status quo no longer helps them. Their posture always served the endpoint of preventing the creation of a national health-insurance plan. Whenever Republicans gain political power, they’ll inherit a system that confers rights upon the previously uninsured. Pretending to care about the uninsured won’t get them anywhere. They may have the votes to change the health-care system, but they’ll be forced to reckon with its effects in an actual way, not as a hypothetical they can engage with or ignore as it suits them. The game has been changed. And, as the disintegration of the latest GOP health-care plan shows, the Republican Party is not yet remotely prepared to play it.