- Conservative market-oriented health policy scholars have developed a rich menu of potential replacement plans for Obamacare
- It’s arguably the favorite myth of progressives, the oft-repeated claim that Republicans have no health plan
- An individual mandate for comprehensive coverage is a completely different animal than the individual mandate for catastrophic coverage
It’s arguably the favorite myth of progressives, the oft-repeated claim that Republicans have no health plan. Hence, President Obama was fully justified in ignoring them and proceeding to enact a comprehensive health reform law on a strict party line vote—something completely unprecedented in American political history. Karl Rove last week did an excellent job of countering that myth in a Wall Street Journal op-ed. For those who may have missed that piece, or those who want further details and links not feasible to include within the constraints of a printed op-ed, this post is intended to fill in some blanks.
Who is spreading this myth?
Lest I myself be accused of spreading a myth, let’s start with a quick survey of some well-known progressives fond of endlessly repeating this canard.
President Obama. Just last month, President Obama asserted that if Republicans “had some better ideas” on health care, he was “happy to hear them. But I haven’t heard any so far.”
Democratic National Committee. In a press release less than two weeks ago, the DNC claims: “When it comes to the issues that matter to middle class Americans – from health care to immigration reform and energy policy – the GOP is simply out of ideas.”
Paul Krugman. It probably will not surprise anyone to see someone with such a widespread reputation for truth-twisting in general–not to mention health policy—on this list. Just this month, Mr. Krugman has assured us that Republicans have an “obsession with denying insurance to 30 million Americans.” He’s convinced their objective is “to deny essential health care and financial security to millions of their fellow Americans.” In discussing Obamacare’s misguided modified community rating reforms, he sneers “conservatives balk at the notion of any kind of redistribution, even if it makes almost everyone better off. So they are unable to come up with an alternative” (emphasis added: as we’ll see, Republicans have been able and willing for years to offer ample alternatives to creating affordable coverage). And when Republicans such as Rep. Paul Ryan do come up with serious plans to reform an entitlement that the Medicare actuary, Treasury Department, Congressional Budget Office, the non-partisan Peter G. Peterson Foundation (and yours truly) all agree is unsustainable, Krugman’s retort about Republicans is that “They don’t want to make Medicare sustainable, they want to destroy it under the guise of saving it.”
Matt Miller. The Washington Post’s progressive health policy champion has a nifty explanation for why Republicans have failed to come up with a plan that covers as many uninsured at such a low expense as Obamacare: “That’s because the GOP does not view the presence of 50 million uninsured in a wealthy nation as an issue that needs to be addressed.”
Alan Grayson. Along the same lines, there was this classic rant by Rep. Alan Grayson (D-FL):
The Republicans’ health care plan for America: “Don’t get sick.” That’s right — don’t get sick. If you have insurance, don’t get sick; if you don’t have insurance, don’t get sick; if you’re sick, don’t get sick — just don’t get sick! That’s what the Republicans have in mind for you, America. That’s the Republicans’ health care plan. But I think that the Republicans understand that that plan isn’t always going to work — it’s not a foolproof plan. So the Republicans have a backup plan, in case you do get sick. If you get sick in America, this is what the Republicans want you to do. If you get sick, America, the Republican health care plan is this: “Die quickly.” That’s right. The Republicans want you to die quickly if you get sick.
Jonathan Cohn. To his credit, New Republic’s progressive health policy voice is willing to concede “Republicans do have plenty of ideas.” But then he quickly adds: “But they are not the kind of ideas that would come anywhere close to achieving universal coverage, at least in the way most people understand it.” As we will see, Republicans have offered plans that do at least as well as Obamacare in achieving universal coverage.
Ezra Klein. Washington Post’s progressive blogger is similarly dismissive of a plan offered by former Bush HHS staffer Ben Domenech: “This isn’t a plan to ‘replace Obamacare.’ It’s a plan to do the opposite of replacing Obamacare. It’s as if I said I had a plan to fix the house by replacing the leaky roof, and you said you had a plan to fix the house by getting rid of the roof.”
The take-home? Republicans have no health plan. Why? Because they don’t care about the uninsured. It’s fine with them if you get sick and die. Or if they do have a plan, it’s a lousy plan that won’t do much or will cost a boatload of money.
Comprehensive Republican health reform plans introduced in Congress
Let’s start with 5 comprehensive health reform proposals that have actually been introduced in Congress—some well before President Obama even was nominated for president, and all months before the House (11/7/09) or Senate (12/24/09) voted on what eventually became Obamacare.
- Ten Steps to Transform Health Care in America Act (S. 1783) introduced by Senator Mike Enzi (R-WY) July 12, 2007.
- Every American Insured Health Act introduced by Senators Richard Burr (R-NC) and Bob Corker (R-TN) with co-sponsors Tom Coburn (R-OK), Mel Martinez (formerly R-FL) and Elizabeth Dole (formerly R-NC) on July 26, 2007.
- Senators Bob Bennett (R-UT) and Ron Wyden (D-OR) introduced the Healthy Americans Act on January 18, 2007 and re-introduced the same bill on February 5, 2009.
- Patients’ Choice Act of 2009 introduced by Senators Tom Coburn (R-OK) and Richard Burr (R-NC) and Rep. Paul Ryan (R-WI) and Devin Nunes (R-CA) on May 20, 2009.
- H.R. 2300, Empowering Patients First Act introduced July 30, 2009 by Rep. Tom Price (R-GA).
Comprehensive conservative Obamacare replacement plans
Likewise, conservative market-oriented health policy scholars have developed a rich menu of potential replacement plans for Obamacare:
- Individual Pay or Play proposed in 2005 by John Goodman; this is a minimalist version of a broader reform envisaged by Goodman built on converting the tax exclusion into universal tax credits.
- Health Status Insurance originally proposed by John Cochrane in 1995.
- Universal Health Savings Accounts proposed by John Goodman and Peter Ferrara in 2012. This combines fixed tax credits with individual pay or play and health status insurance concepts along with Roth-style Health Savings Accounts.
- Fixed tax credits. A variety of proposals have centered on using fix tax credits to replace the current inefficient and unfair tax exclusion for employer-provided health benefits. Two good explanations of how that would work are here:
- James C. Capretta and Robert E. Moffit, “How to Replace Obamacare,” National Affairs, no. 11 (Spring 2012).
- James C. Capretta. Constructing an Alternative to Obamacare: Key Details for a Practical Replacement Program. American Enterprise Institute, December 2012.
- Income-Related Tax Credits proposed by Mark Pauly and John Hoff in Responsible Tax Credits (2002) and endorsed by the American Medical Association. More recently, 8 scholars from Harvard, University of Chicago, and USC–Jay Bhattacharya, Amitabh Chandra, Michael Chernew, Dana Goldman, Anupam Jena, Darius Lakdawalla,Anup Malani and Tomas Philipson—released Best of Both Worlds: Uniting Universal Coverage and Personal Choice in Health Care (2013) which also is built around a model of individual health insurance subsidized with income-related tax credits.
- Flexible Benefits Tax Credit For Health Insurance by Lynn Etheredge in 2001.
- Near-Universal Health Insurance Exchanges proposed in 2001 by Sara Singer, Alan Garber and Alain Enthoven (covers only non-elderly).
- Universal Health Insurance Exchanges proposed in 2013 by former CBO director Douglas Holtz-Eakin and Avik Roy (covers Medicare and Medicaid in addition to privately insured).
The forgotten history of George W. Bush’s comprehensive health reform plan
Too many people conveniently ignore that in his 2007 State of the Union message President Bush proposed a sweeping health reform plan that would have replaced the current tax exclusion for employer-provided coverage with standard tax deductions for all individuals and families. The Bush plan called for a tax deduction that would have applied to payroll taxes as well as income taxes. Moreover, if one were worried about non-filers, the subsidy could easily have instead been structured as a refundable tax credit in which case even those without any income taxes would have gotten an additional amount. This is the kind of policy detail that easily could have been negotiated had the Democrats been in a cooperative mood in 2007. They were not. On the contrary, President Bush’s health plan was declared “dead on arrival” by Democrats in 2007. Yet it is Republicans who were tagged as being uncooperative and intransigent when they resisted the misguided direction that Obamacare seemed to be headed.
What’s sad is that the Bush plan actually was superior to Obamacare when it comes to providing universal coverage. Remember, Obamacare actually does not provided universal coverage. The latest figures from CBO says that when it is fully implemented in 2016, Obamacare will cut the number of uninsured by only 45%, covering 89% of the non-elderly. Even if illegal immigrants are excluded, this percentage rises to only 92%. In contrast, the Bush plan (without a mandate!) would have cut the number of uninsured by 65%. But that’s ancient history. Consider one of the newest market-oriented health reform plans put on the table by Jim Capretta and Douglas Holtz-Eakin. Compared to Obamacare, this plan would cost roughly the same amount yet cover 22% more (8 million!) uninsured. If there’s a superior alternative to the slow-motion train wreck now being implemented, why wouldn’t the President and Democrats in Congress want to seriously consider it as a replacement?
Of course even those willing to acknowledge Bush’s health reform plan then tend to counter with the claim that he wasn’t “serious” about his proposal. It was just a defensive move to defend Republicans in 2008 against the charge that the Republicans didn’t have a plan because they didn’t care about the issue (sound familiar). Those dubious about GWB’s “seriousness” about health reform should do the following thought experiment. Imagine that the Democrats in Congress had passed a bill containing the Bush administration’s health plan–no more, no less. Does anyone seriously believe GWB would have vetoed that bill? If not, I would argue his proposal was a serious one.
The twisted history of Romneycare
A favorite debate tactic of progressives is to argue that Obamacare is really a centrist proposal modeled on Republican ideas. Mitt Romney was repeatedly vilified for his purported hypocrisy in criticizing Obamacare’s individual mandate in light of his having signed Romneycare into law. But an individual mandate for comprehensive coverage is literally a completely different animal than the individual mandate for catastrophic coverage supported by some conservatives going back as far as the late 1980’s. Avik Roy has done a masterful job of tracing this idea’s intellectual roots. As Mr. Roy has described in great detail, Romney’s visions for health reform was very different than the bill he was actually able to get through a Massachusetts legislature dominated (85%!) by Democrats. Indeed he vetoed 8 different parts of the health reform plan passed by the legislature—including the misguided employer mandate that is now creating so many headaches under Obamacare—but each of these was overridden. Mr. Roy also has patiently explained how Romney’s successor, Deval Patrick further gutted Romneycare’s market-oriented features.
It takes two to tango
The standard progressive meme is that all the divisiveness over health reform is the fault of stubborn intransigent Republicans who stood in the way of reaching a bipartisan compromise. Whether it was because they didn’t care, were out of ideas or simply were Obama haters (the explanations vary), everything would have smooth sailing had President Obama been able to work with a more cooperative Congress. The President’s signature promise in the 2008 election was that he would be a post-partisan president. Yet within days of taking office, he short-circuited discussions with Republicans over the size and nature of the fiscal stimulus package by caustically remarking “I won.” By August 2009, as angry Americans voiced their displeasure with the health care bill, it was clear that his post-partisan promise had fizzled. Following the unprecedented passage of a signature domestic policy bill on a purely party-line vote, seasoned political observer Michael Barone observed:
Things did not have to be this way. Models for bipartisan approaches were there for the taking: the health care proposal sponsored by Democratic Senator Ron Wyden and Republican Senator Bob Bennett; the financial regulation proposals of Republican Senator Bob Corker. But these were brushed aside either by the Obama White House or by Democratic congressional leaders. This has not been the post-partisan era we were promised.
Indeed, Dana Milbank (hardly a conservative) accurately describes what really happened in the health care debate:
Obama’s greatest mistake was failing to listen to Emanuel on health care. Early on, Emanuel argued for a smaller bill with popular items, such as expanding health coverage for children and young adults, that could win some Republican support. He opposed the public option as a needless distraction. The president disregarded that strategy and sided with Capitol Hill liberals who hoped to ram a larger, less popular bill through Congress with Democratic votes only. The result was, as the world now knows, disastrous.
Compromise is a two-way street. Taking an “I won” approach to negotiations isn’t the wisest way to get to yes. We all now are paying the price for a partisan decision to rush through a massive bill against the strong and persistent opposition not only of Republicans, but the American public. When Obamacare passed on March 23, 2010, the RealClearPolitics poll average shows 50.4% of Americans opposed and only 39.7% in favor. And this double-digit margin of opposition was by no means unusual. One year later—despite the firm assurances by President Obama and then-House speaker Nancy Pelosi that the public would come to favor the law once it was passed—opposed stood at 52.3% opposed to 39.7%. Even today, Americans remain opposed 51.5% to 39.5%. In light of these figures, one can reasonably inquire which party was more faithfully representing the views of the public when it came to health reform.
And one can reasonably ask President Obama and Democrats in Congress: when will you listen to the people? Let’s spare the people a train wreck by delaying this law for a year. This isn’t a Republican idea: it’s just plain common sense.