Replace or die.
Vox’s Ezra Klein half-jokingly suggested that “The Republican replacement for Obamacare is Fauxbamacare”:
Scott Brown, [the former Republican Senator from Massachusetts] who’s now running for Senate in New Hampshire, has found the perfect position on Obamacare. He’s for it. He’s just not for calling it Obamacare. In an interview with WBUR, he called Obamacare a “disaster.” Then he was asked what he’s for—and he went on to describe Obamacare.
Brown, according to Klein, now says he is for an individual mandate, for Medicaid expansion, for any number of other core provisions in the president’s health care law. He just opposes the unpopular parts, like the tax hikes and the Medicare cuts, which were included to help pay for Obamacare. Klein writes:
Brown is picking up on a real opportunity here. The polls around Obamacare are frustrating both to the law’s principled supporters and its principled opponents. There is, in theory at least, a huge opening for an unprincipled opponent—someone who opposes “Obamacare”, but supports virtually all of the policies in Obamacare. Someone who supports Fauxbamacare.
Good point. There is an opening here or unprincipled opponents. There’s also an opening—albeit a rapidly narrowing one—for principled opponents. But of that, more anon.
To Klein’s point. Are Republicans silently starting to replace their “repeal and replace” agenda with what amounts to “retain but fix”? There certainly have been some troubling signs this past week. Not only did Brown seem to embrace Fauxbamacare, but House GOP spokeswoman Cathy McMorris-Rogers (R-WA) was widely reported (inaccurately, she claims) to have said we just have to fix Obamacare, and US Senator Rob Portman (R-OH) dodged an interviewers questioning about what should replace Obamacare.
This is playing with fire, especially now, as Rs head into the midterm elections—elections in which they hope to translate popular disgust with Obama and Obamacare into Republican House and Senate majorities.
I can see why Beltway types might assume “retain but fix” is the politically saleable position for centrist voters, who are, after all, tired of the whole debate. But it clearly won’t wash with grassroots conservatives and libertarians, whose desire for root-and-branch repeal is, if anything, more intense than ever. And yet Obama will never sign a full repeal. So what do Republicans do? Klein says: They equivocate. They propose replacing Obamacare with . . . Fauxbamacare.
Klein adds, correctly, that it’s hard to take health care away from “ten million” Americans (and counting). And that Obamacare is really just a version of the old Heritage Foundation plan from the early ‘90s, which Republicans used to be for. And that many of its major provisions poll well, when described individually.
All true. But so what. It seems to me Klein is whistling past the graveyard here. The logical outcome of all this could be a recourse to “Fauxbamacare.” But it could also be a real Republican alternative to Obamacare.
We will soon find out. House Majority Leader Eric Cantor (R-VA) has promised a replacement bill “in 2014.” After this past week, he has no choice but to deliver it before November.
When he does, it will lay to rest the greatest myth of the Great Health Care Debate (that Republicans “have no alternative”). Democrats will find themselves attacking a plan they have always claimed does not exist.
Cantor has a lot of material to work with. He can draw from BrounCare, JindalCare, SasseCare, PriceCare, RoeCare, BoehnerCare, and CoburnCare, to name just seven existing GOP plans. Some are better than others (I’ve compared them in detail), but all are serious and comprehensive; and all would be a huge improvement over the status quo.
The press will never report their existence, however, until House Republicans to start forcing votes on them. That has to change.
The Traps To Avoid
Doing nothing is no longer an option. The recovery of healthcare.gov and the “ten million Obamacare enrollees” have seen to that. So Republicans now have no choice but to play their “replace” card, if they want to keep Democrats from running demagogically on “the Republican plan to take away your health care.” But in doing so, they have to avoid falling into a number of traps:
1) They have to neutralize any demagoguery about those “ten million” people with existing benefits. They should close the gate on any further sign-ups. And make clear there’ll be a transition—that existing “beneficiaries” will have alternatives, and/or a few years to make alternative arrangements as the Republican reforms kick in.
2) They can’t let “universal coverage” (or comparative “coverage gains”) be the measure of their seriousness. That path will lead them into a policy cul de sac where the only choices are onerous mandates and Medicaid expansions—i.e., Fauxbamacare. Instead, they have to focus on reducing costs and expanding individual freedom, consistent with the Constitution.
3) They can’t let their replacement agenda be simply “another symbolic repeal vote.” It has to be a series of actual, serious reforms.
4) They can’t let themselves slip into merely “fixing Obamacare.” That will doom them with their own base voters. Instead, they need to give themselves maneuvering room, by broadening the debate to reforming health care in general.
5) They can’t blow up the employer-based system, from which half the US population get its health coverage. That will doom them with most voters. Instead, they need to leave workplace health benefits in place, but help more people to obtain individually owned insurance outside the workplace.
There’s only one way to avoid all these traps, in my view, and that’s to follow “regular order.” Instead of holding an up-or-down vote on some 2,000-page omnibus bill, take up a series of single-issue bills, and deliberately and thoughtfully consider each one, with plenty of time for careful review, debate, and amendment.
To put a cork in the Democrats’ mouth, Republicans should include in each bill a contingent effective date, along the following lines: “This bill shall take effect upon the enactment of the full repeal of the Affordable Care Act, or on January 21, 2017, whichever is sooner.”
This formulation would enable opponents to navigate the treacherous waters between “reform health care” and “fix Obamacare.” It effectively makes the reform contingent on the election of a Republican successor to Obama, who would presumably be in a position to sign a full repeal, and thus subtly acknowledges the reality of Obama’s veto pen while clearly reaffirming the Republican commitment to full repeal. It also takes away the Democratic talking points about “no Republican plan” and “just another repeal vote”).
GOP leaders should not wait to move until after the election, or until they’ve found consensus among their members on some big package of compromise reforms. Such a consensus may not be attainable. Even if it is, the result is likely to be underwhelming in its totality, overwhelming in its density, confusing in its complexity, and embarrassingly laden with hidden K Street handouts. Blech!
Where To Start
So which bill should Rs take up first? I would suggest they start with one or more bills to expands Health Savings Accounts. That’s safe ground for them. HSAs are popular, and threatened by Obamacare’s rules. Exempt them from Obamacare. Make them more generous. Expand access to them in the workplace and Medicare. Pow, pow, pow.
Second, I would tackle the tax treatment of health care. This will provoke important intra-GOP debates over whether we need new credits or deductions, and how to pay for any new tax breaks. But so what. We need to have those debates.
Third, I would take the fight onto the enemy’s turf by deregulating health care. For example, repeal or amend federal laws like ERISA, HIPAA, and EMTALA, which impede markets and drive up costs.
Now, on some issues, Rs will divide over constitutional issues. I can see that happening with federal malpractice reforms, helping people with pre-existing conditions, and letting people purchase insurance “across state lines.” Again, so what. Let the chips fall where they may. Better to publicly debate controversial ideas than to appear to have none.
Of course, Klein may be right. Fauxbamacare may turn out to be the Republican alternative to Obamacare. But it’s not a politically viable option. And increasingly, neither is doing nothing.
The window is closing. The time has come to put up or shut up. Replace or die.