A quote often attributed to former Ohio State University football coach Woody Hayes suggests “There are three things that can happen when you throw a pass, and two of them are bad.” Apocryphal or not, that’s how I’m starting to feel about the GOP’s plans to repeal and replace Obamacare.
The more I talk to conservative-leaning health care policy experts—sources that had previously helped me understand the debacle that would become Obamacare—the more convinced I am that this could all go horribly wrong.
“The train is rushing down the tracks toward the cliff,” said one health care policy expert.
Or maybe not. Despite President Trump’s issuing of an executive order on day one, congressional plans to repeal the law are reportedly being pushed to mid-to-late February. Having spent the last six (or so) years promising to repeal and replace the Affordable Care Act (aka Obamacare), Republicans now find themselves with the thankless task of fixing America’s health care system.
This forces conservatives into what amounts to a no-win binary choice: Either health care isn’t an appropriate responsibility of government (which is politically untenable—especially when your party’s president disagrees with the premise), or you are attempting to find a more free-market way to do the things Obamacare aimed to do—just with more carrots and fewer sticks.
Conservative philosophy—from Burke to Hayek—suggests that comprehensive plans are a fatal conceit; the world is too complex to plan. The notion that Republicans could magically “fix” the largest sector of the world’s largest economy is dubious, at best.
But that ship has sailed. No matter the fate of the Affordable Care Act, former President Barack Obama already accomplished a huge legacy-guaranteeing paradigm shift: It is now understood that it is the federal government’s job to make sure everyone has access to health care insurance.
Even President Donald Trump agrees with this promise of universal coverage, telling The Washington Post recently: “We’re going to have insurance for everybody… There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
I’ve been through all the conservative alternatives, and many of them have good components. Why not allow people to purchase across state lines? Yes, maybe tax deductions and refundable means-tested tax credits (as Avik Roy’s “Transcending Obamacare” plan suggests) could be used to incentivize obtaining coverage. Portable Health Savings Accounts seem like a fine idea. The new plan proposed by Sen. Bill Cassidy, M.D. (R-LA), and Sen. Susan Collins (R-ME) would create an auto-enrollment feature. And maybe, as Sen. Rand Paul’s (R-KY) plan suggests, virtually anyone will be able to form or join a large group to get coverage.
Each of these plans consists of some good ideas. But it’s like a novice trying to solve a Rubik’s Cube. Every conceivable scheme or solution creates new problems. None of them solve the problem because this problem is simply too complicated to “solve.”
“The idea that in this new political era, Congress and this new administration are going to remake health care is not realistic,” says James C. Capretta, a resident scholar at the American Enterprise Institute (AEI). “There are no simple one-line solutions to the problems. The tentacles of the current system run very deep because the system has been built up over decades. And that means change will necessarily be incremental.”
In other words, instead of throwing a Hail Mary and risking a huge interception, Republicans might be better off just trying to gain a few yards and move the ball down the field.
So how could a realistic (and not disastrous) health care system look? According to Capretta, the most plausible (and simplistic) plan would (A) retain the employer-based system (replacing the “Cadillac tax” with a better designed upper limit), (B) provide tax credits for people outside the system, and (C) provide Medicaid for everyone who can’t afford health insurance.
“You can look at this,” Capretta conceded, “and say, ‘Boy, doesn’t this sound like the Affordable Care Act’? And the answer is ‘yes.’” But the details in this plan are essential. And changing the details to be more market-oriented—more driven by consumer preferences—really makes a difference.”
There is little reason to believe that Republicans will end up with something this simple, but even if they do, it’s not like they will end up with some perfect free-market plan. By winning the presidential election, Republicans are now like the dog that caught the car.
“It feels like Bush’s Social Security all over again,” one senior industry official told me. “It’s really hard to see how this ends up with as many people being covered at the same or lower costs. It’s a mess.”
Even that may be a best-case scenario. Social Security reform was a bust that wasted President George W. Bush’s second-term political capital, but Republicans didn’t repeal Social Security. There is always the danger that this could go catastrophically wrong.
Should Republicans actually kick off a new administration by engaging in a fool’s errand that is almost guaranteed to backfire?
Sometimes you have to punt.