Obamacare is coming. The healthcare exchanges will be open for business as October begins – except in a number of Republican states where they’ll find some way to not provide one. That’s okay, because where a state won’t set one up the federal government will. Those whose employers do not provide health coverage, and those who are still looking for work, and the young who have found that even with their multiple college degrees that the only work available is one more unpaid internship or taking out the trash at the local Starbucks, will be able to buy health insurance cheaply, as part of a large pool. In New York and California, and most other states, the cost of such insurance, once sky-high, is now quite low. The big insurance providers bid for the business and competition did the rest – and those who cannot afford even this surprisingly cheap insurance will be offered subsidies, so they can. This will mean fewer and fewer Americans resorting to free emergency room visits to take care of health problems which have been ignored and then have gotten so bad they’re near death, relieving hospitals of a tremendous financial burden. Now almost every admission will be a paying customer, not a freeloader. Everyone’s insurance rates will slowly come down too. The burden of the freeloaders will ease, and then disappear. This is what is meant about “bending the cost-curve” – healthcare will always get more expensive with technological advances and new amazing drugs, but the obvious dead weight will be removed from the system, or maybe that’s nearly-dead weight. Thirty or forty million uninsured Americans are a lot of dead weight – and that’s only the economic argument for the Affordable Care Act. A healthy population is generally a good thing – it cuts down on epidemics if nothing else – and a population that’s not worried sick that one illness or injury will bankrupt them can worry about other things, like raising good and responsible kids or even starting a business and all the other stuff that make this a pretty good place to live. It’s one less thing to worry about. People can even change jobs, or careers, and not worry about the kid’s case of measles. It frees up people to be all that they can be. What’s not to like?
The counterargument has always seemed to be that this is none of the government’s business, on two counts – first, that taking care of yourself, and making sure you can find sufficient funds to do so, somehow, is a matter of personal responsibility, and the people that have none deserve what they get, and second, that the free market is the way to assure cheap and superbly effective health insurance for everyone, even for those with preexisting conditions and all that, because totally unregulated competition will weed out the crappy stuff, as no one will want to buy it. That’s the Adam Smith Invisible Hand argument. The third argument is ancillary to that – that any system run by the government, or even lightly regulated by the government, will be a mess, because more government is always the problem, never the answer. Ronald Reagan said so. If so, elected officials should have no say in healthcare. They know nothing about it. This could lead to those Death Panels – putting granny down for the greater good, as it was so often put. No one would be truly free anymore. The government would be making life and death decisions for all of us. The Affordable Care Act is an assault on the sacred freedom of all Americans.
As many have pointed out, the dispute was, at its core, about two quite different types of freedom – “freedom from” and “freedom to.” In the end, freedom from worrying about crap that could be taken care of by a little collective action won the day. The Affordable Care Act became law, the law of the land – passed by Congress, signed by the president, declared kosher by the Supreme Court, and is being implemented right now. Republicans never, ever, refer to it as the new law – it’s always the Affordable Care Act “bill” – but then they never speak of the Democratic Party, only the Democrat Party. They do that a lot. The Estate Tax, its actual name, is always the Death Tax. Greedy old rich bastards have estates, but dirt-poor heroic elderly family farmers die too, you see. It’s all in how you frame things. The Affordable Care Act is still a bill. Maybe it hasn’t been passed yet, really.
That’s the general idea, and probably a good number of folks do think this thing isn’t the law yet. Republicans say they can defund it and make it go away, so it can’t be the law, really. Real laws can’t be made to just go away, and certainly not by the House alone, when the Democrats control the Senate and the White House. Obama must be mistaken. Nothing was ever settled. It’s couldn’t have been.
Sowing such confusion has served Republicans well, but now it may have reached its limits. The Affordable Care Act is the law, and to defund it all they have left is to refuse to pass a continuing resolution to fund all government operations, shutting down the entire government unless Obama defunds the thing and makes it go away, or the current thought, waiting a few more months and refusing to raise the debt limit, forcing America to default on all outstanding Treasury bills and causing a worldwide financial collapse unless he does so. Both options are spectacularly counterproductive – it would be national misery or several generations of worldwide misery – one or the other, and something they would have to say they were proud of. Cooler heads in the Republican Party are telling their colleagues not to try either, and they may prevail, or they may not.
That doesn’t even speak to the more fundamental problem. There are still thirty or forty million Americans without health insurance, and thus with no healthcare but for the jammed emergency rooms, and healthcare costs have exploded, year after year, for a generation or more, and no one will cover you if you had acne when you were fourteen. The World Health Organization ranks us thirty-eighth in outcomes and number one in per capita expenditures – so we have a mess on our hands. Obamacare is a start. We have a long way to go, and the Republicans are offering no alternatives. They want to stop Obamacare. That’s it.
Even the always odd Newt Gingrich has noticed this:
“I will bet you, for most of you, you go home in the next two weeks when your members of Congress are home, and you look them in the eye and you say, ‘What is your positive replacement for Obamacare?’ They will have zero answer,” Gingrich said.
Gingrich blamed the problem on Republican culture that rewards obstruction and negativity instead of innovation and “being positive.”
“We are caught up right now in a culture, and you see it every single day, where as long as we are negative and as long as we are vicious and as long as we can tear down our opponent, we don’t have to learn anything,” Gingrich said, acknowledging the “totally candid” nature of his remarks. “We have to do the homework.”
“This is a very deep problem,” said Gingrich.
The Washington Post’s Greg Sargent adds this:
I don’t think this is an accident or an off the cuff remark. It looks to me like there are enough data points out there to suggest that Republicans now recognize that their overall posture on Obamacare – not to mention on the president himself – is deeply problematic, and are seriously grappling with it at the highest levels of the party.
Consider: This is very similar to the warning offered this week by Dave Winston, a veteran pollster and adviser to the House GOP leadership. In an interview with the well-connected Robert Costa, Winston knocked down the idea of a shutdown as follows: “The electorate expects Congress to govern. House Republicans are going to offer their health care alternatives within that process.”
Yeah, but they haven’t, and the Post’s Ezra Klein adds this detail:
The opening session of the Republican National Committee’s Boston confab featured ex-speaker Newt Gingrich scolding his fellow Republicans on their failure to come through on the “replace” side of “repeal-and-replace.”
“If we’re going to take on the fight with Obamacare, we have to be able to explain to people what we would do to make your life better,” he said.
That’s what this was all about in the first place, even if some have lost sight of that:
The simplest way to understand that policy vacuum is to understand Gingrich’s pre-Obamacare health-care plan: It was Obamacare.
“We should insist that everyone above a certain level buy coverage (or, if they are opposed to insurance, post a bond),” he wrote in his 2008 book, “Real Change.” “Meanwhile, we should provide tax credits or subsidize private insurance for the poor.”
So that’s an individual mandate plus tax subsidies to purchase insurance. That’s the core of Obamacare. And it’s no surprise Gingrich supported it. Lots of Republicans did. Gov. Mitt Romney even signed a plan like that into law in Massachusetts.
Now they’ve abandoned that:
Conservative elites had two options when Democrats began to adopt their policy ideas: Declare victory or declare war. Key figures like Gingrich could’ve stepped before the cameras and chortled about Democrats giving up on single payer and slinking towards conservative solutions. For Hillary Clinton to run in 2008 with Bob Dole’s healthcare plan was an amazing moment in American politics. For Barack Obama to reverse himself on the individual mandate and embrace the Heritage Foundation’s approach to personal responsibility was further proof that Democrats had lost the war of ideas here. Republicans could have declared victory and, by engaging constructively, pushed the final product further toward their ideal.
They chose war instead. And that meant eradicating any trace of support for the policies they had come up with.
That’s exactly what they did:
Republicans quickly convinced themselves they had always been at war with Oceania – excuse me, the individual mandate. But plausible healthcare plans are hard to come by. Even the plans that weren’t exactly like Obamacare were too similar to Obamacare for comfort.
And so, five years later, even leading Republicans haven’t really come by another one. There’s a gaping hole where the party’s healthcare plan is supposed to go. Of course the public doesn’t trust Republicans on the issue. Republicans don’t even know what they’d do.
Klein argues that Republicans have erected a culture in which they have had to unlearn things, and the irony is that Gingrich has been part of that effort, for what that’s worth.
The problem is that it’s too late now. There can be no Republican alternative to Obamacare, ever, as Jonathan Bernstein sees things now:
The first problem with developing an alternative to the Affordable Care Act is that there just may not be any policy alternative that comes close to accomplishing what the law accomplishes. At first, it looked like conservatives would leave themselves a way to propose their own version of the same reforms in Obamacare, and rename it on their own terms. As such, there seemed to be a method to it when, at the outset, conservatives worked hard to prevent an actual discussion of the substance of the law itself. Much of the initial hatred of the ACA was focused on a series of phony talking points and outright lies (“government takeover” of health care; “death panels”; the law was “rammed through” using corrupt procedural tricks; etc.).
Since none of that was true, it gave Republicans an opening: they may have stigmatized “Obamacare,” but they hadn’t stigmatized the policy ideas at the core of the law – the combination of exchanges and subsidies that actually started out as a Republican plan… In other words, as late as 2012 it seemed plausible Republicans could choose to invent a ConservaCare proposal based on Ronald Reagan Marketplaces that would basically offer a slightly different spin on the same underlying idea.
But conservatives have decided that no policy overlap with Obamacare is acceptable. Tea Partiers have chosen to oppose not only Obamacare but any policy which even faintly resembles any piece of that omnibus legislation. We saw this in the House defeat of Eric Cantor’s high-risk poll bill this spring, when conservatives revolted against his effort to propose a GOP plan protecting those with preexisting conditions.
They’ve hit a brick wall:
Thanks to the way that the ACA was put together – it really is a mammoth omnibus bill which incorporated practically every plausible policy idea out there – it turns out that practically everything you can do to provide health insurance is now tainted by Obamacare.
That leaves them nowhere to go, except to turn against the whole concept of health insurance itself, which Ed Kilgore describes this way:
We see a growing tendency to oppose the very idea of redistribution of risk and cost, which is essential not just to public health reform efforts, but to private health insurance. Conservatives often seem to want to go back to those days when patients paid doctors with cash or did without healthcare altogether. That’s “personal responsibility” with a vengeance.
Bernstein also cites the Washington Examiner’s Philip Klein, arguing here that in those state healthcare exchanges “purchasing health insurance, in aggregate, is a bad deal for younger Americans.”
Well, yes, but only in the sense that purchasing any kind of private insurance, in aggregate, is always going to have a negative expected value. Otherwise no one could make profits from selling it!
In practice, this has meant a conservative fixation on the supposedly bad deal Obamacare offers “young healthies,” who serious conservatives such as Klein and Ross Douthat have argued should only want catastrophic insurance, while conservative activists have taken to arguing they go without insurance altogether.
That’s the logical endpoint, isn’t it? If everything – even the whole concept of insurance – is tainted by association with Obamacare, then the only safe ground for conservatives (safe, that is, from cries of “RINO”) is to oppose insurance altogether. After all, as Ezra Klein notes, “plausible health-care plans are hard to come by.” So it’s not as if the leap to opposing the concept of insurance is leaving anything obvious behind.
Think it through:
There’s simply no way to construct a real, workable health care reform plan that (1) is based on private insurance, and (2) avoids any of the elements of the Affordable Care Act. There just isn’t any policy space there. Since Republicans aren’t going to embrace public insurance as an alternative, that’s leaving them increasingly ready to oppose any kind of insurance at all. That makes a straight Obamacare repeal a seemingly logical option; there’s no reason to replace it, since there’s no point in public policy designed to share risk. And as a bonus: if insurance itself is a bad thing, or at least not something essential, then it’s not really a disaster that repealing Obamacare would leave millions without insurance.
Yes, real men don’t buy insurance. No one who has any sense of personal responsibility ever would. That is where the argument leads, although Ed Kilgore adds more:
If you go back far enough to recall that what became Medicaid was originally a Republican alternative to universal health coverage, the repudiation of their own ideas in the war on Obamacare becomes pretty much complete. But the GOP’s problem on health policy goes deeper than having to erase their own tracks.
It goes beyond that growing tendency to oppose the very idea of redistribution of risk and cost, as there’s this too:
An inability to accept the need for national regulation of health insurance: The single biggest trap for Republicans on health policy right now is the wild popularity of measures to end discrimination against people with pre-existing health conditions. There is no way to effectively make that happen without national regulation of health insurers. Instead, GOPers are moving in the opposite direction, with their “interstate insurance sales” gimmick that effectively preempts state regulation of insurers without substituting federal standards.
A habit of opportunistic defense of the status quo: Is there any bad feature of the health care status quo that Republicans haven’t championed in their fight against Obamacare? I can’t think of any. They’ve cheered for strict fee-for-service medicine, letting providers determine their own Medicare and Medicaid payment rates and maintaining higher public subsidies for expensive Medicare Advantage plans. And they’ve opposed virtually every effort to bring down health care inflation that doesn’t simply reduce benefits or shift costs to consumers. It’s hard to be for “reform” when you’re running around frightening old folks with bogus threats to Medicare as they know it. And when you’ve turned the very idea of public efforts to restrain health care costs into “rationing” and then “death panels,” how can you engage in sensible discussions on this topic at all?
Kilgore can’t see the Republicans offering anything at all:
I don’t know how the GOP overcomes these problems without a significant change of course. It’s not like Republicans can just instruct the wonks at their think tanks to go back to the drawing board and come up with something new and cool now that the party has rejected their last generation of health care ideas. Such ideas simply may not exist without a change of philosophy. And so GOP pols keep going back to the same pet rocks like Health Savings Accounts and interstate insurance sales and high-risk pools, which don’t make any more sense than they did twenty years ago. It would almost be funny if real lives were not at stake.
That’s the thing. Lives are at stake, and the Affordable Care Act really is the law of the land. Pouting won’t change that, nor will temper tantrums, and threatening to cause untold misery here or all around the world won’t really get rid of this law that was passed, nor will one more self-righteous lecture about personal responsibility and the moral inadequacy of those who just don’t have enough of it, even if they’re working three jobs and really do. The thing was passed fair and square, and declared quite constitutional by the Supreme Court, and that’s that. There will be any number of problems implementing it – everyone knows that and expects that – but this will make life a lot better for millions of people, and make them freer to get on with the business of life.
Newt had the right idea. Republicans have to be able to explain to people what they would do to make your life better. No one’s heard any of those in years.