Continuing on the “What Are Conservative Policy Ideas for Replacing ObamaCare?” Beat: (Early) Wednesday Focus
I read Reihan Salam over at Slate.
My first, minor, thought is that the Slate editors seriously fell down on their job in failing to demand even a modicum of intellectual consistency here. Let me endorse Brian Buetler:
…to obscure and delay transfers so that budget analysts wouldn’t treat the law as they might a single-payer program where… everything coming in is a tax, and everything going out is an expenditure…. The right’s memory has grown conveniently spotty…. In 2011, in a different context, Salam mocked the kind of scolding he’s now directing at Obama. ‘Ah, he made the program marginally less politically poisonous, which will make it harder for us to demonize him. Now let’s attack him for hypocrisy!’ he wrote, paraphrasing critics. The policy architect in that instance was Paul Ryan, who proposed phasing out the existing Medicare program, but only after 10 years, and only for future retirees. At the time, Salam didn’t believe his opponents’ rhetorical strategy had much merit. ‘I mean, I get it,’ he added. ‘But also: let’s move on’…
My second, big, thought is that there are no live policy ideas–that the Republicans are now the captives of the nihilists they have turned their activist base into, and that their only strategy now is to hope that somehow, some way, ObamaCare can be made to collapse.
I came to this thought as I noted Salam ending his piece with:
when the entire gravamen of the piece had been that there was no alternative that could command anything like even a near-majority of the Republican base.
But let’s back up. Let’s listen. The beginning:
Reihan Salam: “If you don’t read the conservative press…
…you might have no idea why those of us on the right side of the political spectrum are so worked up about Obamacare. To promote cross-ideological understanding, I’ve prepared this little FAQ…
In my view, he is engaging in false advertising here: I read that conservative press. I don’t understand any reason other than the naked pursuit of partisan advantage that Reihan and company are so worked up about Obamacare. And this piece simply confirms me in that view.
Continuing:
At least some [conservatives] like Avik Roy of the Manhattan Institute… believe Obamacare should be reformed and not repealed…
A little insight into why Avik thinks it needs to be reformed and not repealed, and what reforms he wants, would be useful–but that insight is not forthcoming.
Conservatives… would like to see it repealed for several reasons. First… it subsidizes insurance coverage for people of modest means by raising taxes on people of less-modest means…. Conservatives tend not to be enthusiastic about redistribution…
As I see it, there are three possibilities:
- Poor people don’t get to go to the doctor–and die in ditches.
- Poor people get to go to the doctor, but the doctors who don’t treat them don’t get paid and have to scramble to charge somebody else via various forms of cost-shifting.
- The government subsidizes insurance coverage for people of modest means by raising taxes on people of less modest means.
In my view, Slate’s editors seriously fell down on the job in not requiring that Salam say whether he thinks it is better to go for (2)–imposes in-kind taxes on doctors–or (1) rather than (3). The view on the left and in the center is that (1) is a non-starter. As Margaret Thatcher said back in 1993 when she visited Washington, DC: “Of course we want to have universal health care! We aren’t barbarians!” The view on the left and in the center and on the not-insane right is that (2) is profoundly dysfunctional and would prove extraordinarily inefficient. If Salam prefers (1), he should explain why Margaret Thatcher was a squishy leftist. If Salam prefers (2), he should explain why he disagrees with every single technocrat who knows about the health-care financing system.
Continuing, we find Salam still beating the drum of the now-exploded myth that ObamaCare will lead to rapidly-rising health-care costs:
Second, there is a widespread belief on the right that the main driver of the federal government’s fiscal woes is the soaring cost of health entitlements, like Medicare and Medicaid. Champions of Obamacare claim that the law will improve matters…. Conservatives are skeptical…. Instead of tackling the health entitlement problem, say conservatives, Obamacare will make matters worse…
Actually, no. Conservatives don’t say that any more:
(August 2012): Romney’s right: Obamacare cuts Medicare by $716 billion. Here’s how: “The Romney campaign has gone on the offense on Medicare…
…charging that the Affordable Care Act ‘cuts $716 billion’ from the entitlement program…
By far the greatest and high-volume component of the conservative critique of ObamaCare is that it does cut the projected growth rate of Medicare spending.
Finally:
Most conservatives believe that America needs a [different] system…. The problem, as we’ll see, is that there’s not a lot of consensus around what an Obamacare replacement should look like…
And:
Wait a second. Isn’t Obamacare actually a Republican plan? While Democrats were pushing for Obamacare, Rep. Paul Ryan, the Republican from Wisconsin, was pushing for an ambitious Medicare reform that bore a strong family resemblance to Obamacare…. Was it because he—along with all other anti-Obamacare Republicans—is a hypocrite? Well, no…. To put it crudely, the goal of Ryan’s Medicare reform was to move from more socialism to less socialism…. The problem with Obamacare, for Ryan and others on the right, is that it moved America’s health system in the wrong direction, from less socialism to more socialism…
Why are ObamaCare’s hopes to move Medicare toward a “premium support” model “more socialism”, while Paul Ryan’s hopes to move Medicare toward a “premium support” model “less socialism”? Reihan leaves that as an exercise for the reader.
Similarly, ObamaCare’s health exchanges look a lot like RomneyCare’s health exchanges:
There is nothing wrong in principle with establishing marketplaces where people can buy insurance…. The Obamacare exchanges aren’t best understood as simple marketplaces, where the main role of regulators is to ensure transparency. Rather, they serve as central planning boards that establish coverage mandates and review rates. You might think that’s a good thing or a bad thing, but it definitely limits opportunities to offer new types of coverage and new models for care delivery…. When you look at Obamacare as a law that greatly increases federal regulation of the insurance market… it is not ideal from a conservative perspective…
The problem–as Reihan knows–is that it is very difficult to make a competitive market function rather than collapse in any situation in which one side of the market knows a great deal more than the other about the value and cost of what is being bought and sold. That is true in spades of health insurance: the insuree knows much more about his or her health and thus can calculate his or her likely future health-care costs much better than the insurer. Thus to make a health-insurance market function you need to properly structure the market with what Salam calls “coverage mandates and review rates” by “central planning boards”.
How do we know Salam knows this? Because he says so:
The individual mandate? Wasn’t it dreamed up by the right-wing Heritage Foundation? The individual mandate has a long, tortured history…
That is, if you didn’t get it, a “yes”: the central planning boards with their coverage mandates was the Heritage Foundation’s best guess as to how to make a competitive health-insurance market function rather than collapse.
But, Salam says, the conservative economists who understood the issue and their elected political allies failed to communicate with the Republican base:
The pre-Obamacare conversation about the individual mandate never really reached the conservative grass roots, where infringing liberty is generally seen as a no-no. Just as… John McCain’s support for cap and trade… [did not mean] Joseph J. McCoalburner also favored hiking oil prices to save the polar bears… the Republican masses didn’t greet the idea of an individual mandate with wild enthusiasm…
If you didn’t get that, this is the executive editor of National Review saying: “what we have here is a failure of National Review to communicate what conservative policies were. And because what we have here is a failure to communicate, we must now oppose our own policies. This is somehow Obama’s fault.”
But, Salam says, nothing to see here! Move along!:
Conservatives have other ideas for addressing the problem…. James Capretta has called for low-cost default insurance, in which state governments would automatically sign you up for cheap coverage, but you could opt out at any time. Though many conservatives balk at this kind of soft paternalism, it would almost certainly mean higher coverage levels than a weak individual mandate…
Automatically signing people up for low-cost default insurance has other names: Single-payer. Public Option. Even with “soft paternalism”, these ideas are much less to the liking of the Republican base than are the exchanges at the heart of what was once RomneyCare.
Salam concludes:
Do Republicans have any ideas for replacing Obamacare, or do they intend to repeal it and just leave everyone who needs health insurance in a lurch? There are a number of reform proposals that have been floating around…. I expect we’ll see more of them…. When three Republican senators teamed up to release their own health reform plan… they limited the credit… [left] out a decent number of middle-income families. Other conservatives, like Bobby Jindal, the profoundly unpopular Republican governor of Louisiana, have proposed even stingier plans, which will have a tough time passing muster in the post-Obamacare era. This is part of why the aforementioned Avik Roy has argued that conservatives should just accept that Obamacare is here to stay…
That, if you missed it, is a “No. They don’t have any ideas.”