‘Mr. President, tear down this law’: Considering conservatives’ hostility toward Obamacare

August 22, 2013

By Matthew E. Milliken
Aug. 22, 2013

With key deadlines for implementing President Obama’s Patient Protection and Affordable Care Act approaching — except for when the president himself puts them off, that is — a subgenre of conservative punditry has arisen. The theme that unites this new category of opinionating is that its authors all call for Republicans to unite around a replacement set of health care reforms.

It’s long been clear that Americans on the right dislike, if not outright despise, the Affordable Care Act, a.k.a. Obamacare. Their opposition is ironic for at least two reasons. One is that the conservative Heritage Foundation devised the individual mandate to purchase health insurance that is at the heart of the plan.

The other is that Obamacare is predicated, through that very same individual mandate, upon expanding the customer base of health insurance companies. In other words, the Affordable Care Act is simply not a single-payer system, in which the government assures every citizen a minimal level of health care. And Obamacare really isn’t much of a step toward socialized medicine, which significantly increase government control or regulation of the people and institutions that actually dispense health care.

Back in June, Ramesh Ponnuru published a lengthy essay on the National Review’s website that took conservatives to task for

increasingly embracing [this] theory about Obamacare: It’s going to collapse of its own weight, and its failure could yield a sharp right turn in the 2014 and 2016 elections. That theory is probably wrong, and dangerously so. To be rid of Obamacare, Republicans will have to do more than just wait for it to go away — and more than they have done so far.

Recent public remarks by Obama reinforced Ponnuru’s criticism that GOPers need to get more specific about enacting a replacement for Obamacare. Here’s an excerpt from a White House transcript of the president’s Aug. 9 press conference:

Now, what happens on October 1st, in 53 days, is for the remaining 15 percent of the population that doesn’t have health insurance, they’re going to be able to go on a website or call up a call center and sign up for affordable quality health insurance at a significantly cheaper rate than what they can get right now on the individual market. And if even with lower premiums they still can’t afford it, we’re going to be able to provide them with a tax credit to help them buy it. And between October 1st into March there will be an open enrollment period in which millions of Americans for the first time are going to be able to get affordable health care.

Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number-one priority. The one unifying principle in the Republican Party at the moment is making sure that 30 million people don’t have health care and, presumably, repealing all those benefits I just mentioned — kids staying on their parents’ plan; seniors getting discounts on their prescription drugs; I guess a return to lifetime limits on insurance; people with pre-existing conditions continuing to be blocked from being able to get health insurance.

That’s hard to understand as an agenda that is going to strengthen our middle class. At least they used to say, well, we’re going to replace it with something better. There’s not even a pretense now that they’re going to replace it with something better.

The following week, John McCormick of Bloomberg News filed this report from Boston after former U.S. House Speaker Newt Gingrich spoke at the start of a Republican National Committee meeting:

Saying that most Republican lawmakers have “zero answer” for how they would replace “Obamacare,” Gingrich also said, “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.”

He termed that approach “a very deep problem.”

“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,” Gingrich, a former U.S. representative from Georgia and House speaker, later told reporters. “It can’t just be going back to the world that led to Obamacare.”

On Aug. 16, a day after McCormick’s report, Lanhee Chen, policy director for Mitt Romney’s 2012 presidential campaign, and Deroy Murdock, a Fox News contributor and syndicated newspaper columnist, both picked up on this theme.

In National Review, Murdock expressed outrage at Obama’s remarks, even though he offered no evidence that the president was actually wrong about Republicans’ seeming unwillingness to enact any legislation to replace Obamacare. (Tellingly, Murdock’s piece was headlined “Wanted: A Republican Substitute for Obamacare“ and subtitled “To be a credible opponent, the GOP must unite around a plan of its own.”) Writes Murdock:

Unless Republicans want Obama to keep spouting such nonsense, they must craft and at least pass through the GOP House a bill that would scrap Obamacare and put something far better — and Republican — in its place.

After devoting a few sentences to arguing that “Obamacare has become both unworkable and a knee-slapping mockery of its official title: ‘The Affordable Care Act,’” Murdock continued:

That said, congressional Republicans badly need to plant their rumps into some hard chairs and unify around a single GOP alternative to Obamacare. They should endorse its elements, pledge to adopt it if they win the Senate, and constantly sell it as the best means to prevent this looming disaster.

Chen’s Bloomberg View column begins thusly:

President Barack Obama has lost almost all credibility defending the Affordable Care Act: Hiccup after hiccup have marred its implementation, its taxes and spending will hurt economic growth, and it will raise consumer health costs. But Obama may have had a point when he charged last week that Republicans are talking about repealing the law without saying what should replace it.

Republicans would be wise to debunk the president’s claim head on. Recently, we have focused almost all of our energy and effort on the question of who is “purer” or “more conservative” in the fight to repeal Obamacare. Let’s just agree that every Republican wants to repeal Obamacare. Now it’s time to coherently articulate a vision for what should replace the fundamentally flawed health-care law. A failure to do so could have electoral consequences in 2014 and beyond.

Both Chen and Murdock, like Ponnuru before them, go on to share some ideas about how to replace Obamacare. Before I take a quick look at their concepts, however, let’s consider the health care reform landscape for a moment.

I’m by no means a policy expert, but it seems to me that generally there are only a few types of health care systems. One is the status quo, pre-Obamacare, which involves a pastiche of government coverage (Medicare and Medicaid) alongside an inconsistent network of private insurance, some of it made available through employers and some of it sold on the market. As we know, this system has a bunch of flaws, not least of which is the fact that it effectively leaves many millions with limited access to health care.

Another option involves some kind of universal coverage offered through the government, whether it involves outright government control of health care (socialized medicine) or government sponsoring at least some minimum level of coverage for each citizen (single payer). Whether or not such a system would be a good idea from a policy perspective, Obama and his allies deemed it politically unfeasible at the beginning of his administration. A centralized program almost certainly would be even less likely to win legislative passage today. Writes Ponnuru:

Republicans’ confidence that Obamacare will collapse has contributed to their lassitude in coming up with an alternative. It is a perverse complacency. If the program were going to collapse in the next three years, it would be all the more important for Republicans to build the case for a replacement for it. We can be sure that the Left would respond to any such collapse by making the case for a “single payer” program in which the federal government directly provides everyone insurance.

But set aside these centralized reform programs and the alternatives are relatively sparse. One is that the United States keeps the status quo, with all its imperfections. Another is that it proceeds with Obamacare, with modified or not, with all its imperfections.

Ah, but there’s a third option: The U.S. could adopt some patchwork regimen that would, in its way, be more or less as flawed as the Affordable Care Act. 

This situation poses several problems for Republicans. One is that some of the reforms conservatives propose might not be very effective at expanding the number of people with health insurance. Here are a few of Ponnuru’s recommendations:

First, the current tax break for employer-provided insurance, which is more valuable the more expensive the insurance plan is, would be flattened. That way, employees who chose to buy cheaper policies and pay for routine expenses out of pocket would keep the savings, while employees who chose more comprehensive plans would pay the full freight for the extra coverage. Second, the tax break would be extended to those people who buy insurance on their own because they do not have access to an employer plan. Third, insurers would be allowed to sell those individual plans across state lines.

Compare those with these elements of Murdock’s reform proposal:

• Create a robust market in which individuals — not bosses or politicians — can choose to own and control portable health plans.

• Shift tax-deductibility of health premiums from employers to employees, to help workers purchase the coverage that they — not CEOs or senators — prefer.

• Let Americans purchase health and pharmaceutical policies across state lines, just as they now may buy life, home, and apartment coverage from vendors across the U.S.A.

• Free Americans to open voluntary, tax-free Health Savings Accounts from which they can finance over-the-counter drugs, routine medical care, and catastrophic insurance for severe ailments.


• Reform the medical-malpractice system, which propels health costs skyward.

• Establish high-risk pools to help insure those with pre-existing conditions.

• Limit federal involvement to supplying health-insurance subsidies to those remaining Americans who cannot care for themselves or find relief through civil society, local and state government, or the initiatives outlined above. Rather than ruin medicine for 316 million people, government should assist the tough cases who cannot secure help elsewhere. Instead of disastrous micromanagement, Washington simply should offer direct cash payments to help the truly needy and infirm buy private health plans that satisfy their needs.

Now check out some of Chen’s suggestions:

Republicans have avoided the discussion of what should replace Obamacare because there are divisions within the party over the best policy approach. There is broad agreement that cost remains the primary problem, so policies that speak to this concern — enabling the interstate purchase of health insurance, reforming the medical liability system, and bringing greater transparency to the pricing of medical procedures — are broadly popular. Republicans also agree on changing the existing tax treatment of health care, which discriminates against those who obtain health insurance on their own, rather than through employers.

Note the commonalities among these suggestions. And note, too, Slate blogger Matthew Yglesias’ critique of Chen’s editorial:

These ideas are not ideas that will help low-income Americans who lack employer-provided health insurance obtain insurance. Nor are these ideas that will help people whose pre-existing medical conditions have left them locked out of the system obtain insurance.

But ineffectiveness isn’t the only problem with these possible Obamacare substitutes. Another issue, at least for conservatives, is that various aspects of these potential replacement programs resemble Obamacare itself. Chen, for instance, wrote that U.S. Sen. John McCain (R-Arizona) proposed during his 2008 presidential campaign that every American receive a refundable tax credit to defray the cost of health-care coverage. That’s a broader initiative than the one Murdock endorses, which involves the federal government giving cash to help the needy and infirm buy insurance privately.

But these ideas are both similar to a provision of the loathed Obamacare: The law’s subsidies for those earning up to 400 percent of the poverty line, which is about $46,000 for an individual and $94,000 for a four-person family. The Kaiser Family Foundation estimates that 48 percent of Americans who buy individual insurance today are eligible for these subsidies. The foundation, CNN reports, also calculates that those getting federal offsets would receive an average of $5,548, covering about two-thirds of the cost of coverage.

In other words, Chen and Murdock both want to scrap Obamacare, a program that (in part) gives Americans money to help them afford health insurance, in favor of a replacement program that (in part) would give — or give back — Americans money…to help them afford health care. How much sense does that make?

Ezra Klein and Evan Soltas wrote about Republicans’ tortured relationship with Obamacare the other day in The Washington Post.

But for all Gingrich’s bluster on the subject, 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.

So conservatives are in a bind: Either they support the Affordable Care Act, which incorporates ideas the conservatives used to like; they support something like Obamacare; they support something more radical than Obamacare, such as a single-payer or socialized system; or they support…nothing at all.

Oh, but it’s actually just slightly worse than that. Paul Waldman of The American Prospect argued in June that the Republican party is not just anti-Obamacare, it’s generally against anything that would help more Americans get health care. Waldman writes:

Republicans care about taxes whether or not at the moment we happen to be having a big public debate about taxes. But if we weren’t debating health care, they wouldn’t be staying up nights coming up with interesting solutions to health-care problems, because it just isn’t their thing.

Also in June, Mother Jones blogger Kevin Drum picked up on Waldman’s article, arguing that Republicans

opposed Medicare. They opposed CHIP [Children’s Health Insurance Program]. They’ve opposed every expansion of Medicaid ever. Only brutal strongarm tactics got them to support their own president’s prescription drug plan, despite the sure knowledge that killing it would likely lose them the White House the following year [in the 2004 election]. And of course, they’ve opposed every Democratic attempt to pass universal healthcare legislation in the last century.

During that same period, Republicans have never shown any interest in a plan of their own. They periodically put on a show whenever Democrats propose something that looks like it might have legs, but it’s purely defensive. When the threat goes away, so does the show. This has happened like clockwork for decades.

There is no way — repeat: no way — to broaden access to healthcare without spending more money. That’s something Republicans have never been willing to do, and they’re less willing now than ever.

Writing just the other day, Yglesias sounded a note very similar to Drum:

You can’t provide a valuable service to people without spending money. In this case you have to spend the money on low-income people. And Republicans don’t believe in spending money on helping low-income people.

These are uncharitable motivations to ascribe to conservatives, of course. Unfortunately, most of the available evidence suggests that these inferences are quite accurate.

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