Conservatives have no ideas to help “[bring] care to the uninsured, or those with pre-existing conditions.” Heard this before? It’s the New York Times editorial board’s favorite meme.
It’s certainly true that Republicans haven’t collectively endorsed a “replace” plan to go with their “repeal” strategy. Part of the reason is tactical—while polls find ObamaCare consistently unpopular, Republicans hesitate to put forth their own comprehensive plan that would (undoubtedly) attract its own critics. (Similarly, the president keeps postponing a final decision on the Keystone XL pipeline—an equally transparent political strategy.)
Meanwhile, ObamaCare implementation has marched ahead, enrolling approximately 8 million Americans through state-and federally-run insurance exchanges. And a plurality of Americans now say they want the law fixed, rather than repealed. Does this signal that ObamaCare debate is “over,” and that Republicans and independents must learn to like it?
Hardly. ObamaCare isn’t out of the woods yet – the newly insured through the law’s exchanges are turning out to be significantly sicker than the uninsured, and may help to end the “great stagnation” of health care pricing. If second-year premiums turn out to be significantly more expensive, it will be ever more difficult to bring in the young and healthy, who benefit less from federal subsidies.
All of this provides an opportunity for critics to deploy some political ju-jitsu. Creative conservatives and flexible moderates should be able to turn components of ObamaCare amenable to market reforms into legislative changes a majority of Americans—including some Democrats—would support. This strategy would also draw on smart plans already on offer from leading conservatives in the House and Senate.
Want to reform the individual insurance market? The Patient CARE Act (PCA), drawn up by Senators Coburn (Okla.), Burr (N.C.), and Hatch (Utah), proposes deregulating ObamaCare’s exchanges, offering consumers a wider range of affordable plans. The CARE Act also caps the tax advantage of employer-sponsored coverage to help finance subsidies for the poor rather than middle-class, eliminating the “coverage gap” under ObamaCare.
What about Medicaid? Rep. Bill Cassidy (La.) resurrected a Clinton-era proposal, which would create per-capita caps for Medicaid enrollees. States would receive funding based on per-person costs (the disabled, elderly, and single mothers could receive tailored financial support), accommodating growth in enrollment but keeping total Medicaid costs under control—unlike ObamaCare, which merely shovels money at the program.
Republican governors have also proposed far-reaching health care reforms, including a form of “loser pays” medical malpractice reform in New Hampshire; moving more able-bodied Medicaid enrollees into private insurance; and requiring them to seek work in return for benefits (à la welfare reform).
Conservatives have supported numerous reforms to break up hospital monopolies, and introduce market competition into health care services and delivery, too. With more Americans gravitating to high deductible plans on ObamaCare exchanges, regulatory reforms present a terrific opportunity to make health care more patient-and consumer-friendly.
In short, conservatives can choose from a wide range of thoughtful, substantive reforms that will help make insurance more affordable and improve health care for millions of Americans.
Elections have consequences—as Republicans have learned since the last presidential election.But American health care is still extraordinarily expensive, and government entitlements are still on track to eat up every dollar of federal revenues, without extensive reforms.
Telling conservatives to “shut up” would rob the country of meaningful debate over real, pressing problems. Moreover, true reforms don’t have to wait for repeal of the law—and certainly wouldn’t end with repeal, in any case.
Good policy, rather than political expediency, should come first. As it is, ObamaCare is far from good policy. Even relatively minor changes, like repealing the employer mandate, can thus vastly improve the law.
And, perhaps, lead to much bigger changes in the not-too-distant future.
Yevgeniy Feyman is a fellow at the Manhattan Institute. He writes on health care policy, entitlement reform and the Affordable Care Act.
Paul Howard is a Manhattan Institute senior fellow and director of the Manhattan Institute's Center for Medical Progress.