Philip Klein is one of the right's smartest health-care writers, and in the aftermath of King v. Burwell, he has some advice for Republicans: they need "to lay out a detailed vision for market-based system, and to spend the next election doggedly making their case."
This is not going to happen. Republicans are never going to unite around a serious replacement for Obamacare and endure the political pain necessary to get it passed.
How do I know? Well, I read Overcoming Obamacare, Klein's excellent book on Republicans and health-care reform. And as Klein writes there, Republicans don't care that much about health reform. "Health-care policy has traditionally only been a motivating issue for conservative activists when it comes to opposing liberal attempts to expand the role of government."
This is the key difference between Democrats and Republicans on health reform. For Democrats, universal health care is a great moral crusade. It's one of the core purposes of the Democratic Party. Democrats wanted to pass health reform more than they wanted to win the 2010 election. They were willing to have the internal party fight over what kind of plan to support, and then to go through the brutal legislative process required to make that plan into a bill, and then go through the political hell of canceling people's plans and implementing their replacement.
Republicans hate Obamacare. But every time they actually try to come up with a plan to replace it, they run into the same damn problem — and it reminds them why they never prioritized health reform in the first place.
Why Republicans hate health reform
One of the most perceptive points in Klein's book comes from Cato's Michael Cannon, one of the architects of the King v. Burwell case.
"Conservatives are falling into the same trap now that they fell into with fighting the Clinton health plan ... they’re conceding the left’s premises that the government should be trying to provide everybody with health insurance, or the government should be trying to expand access to health insurance, or the government should be subsidizing health insurance, because some people need help and therefore the federal government should be the one to help them. The problem [comes] because once you accept those premises, all of your solutions look like the left’s solutions. They look like Obamacare. And so a lot of conservatives, as much as they want to repeal it and say they want to repeal Obamacare, they’re still pushing replace plans that amount to ‘Obamacare Lite.’"
Cannon is right. The basic project of health reform, at least as it's been understood in American politics in recent decades, involves the government giving money to poor people so they can buy health-care insurance. That money needs to come from somewhere. The government usually gets it from politically unsympathetic constituencies like the rich and corporations, both of which lean Republican. In the case of Obamacare, Medicare cuts were added to the package, meaning another Republican-tilting constituency — the elderly — absorbed the pain.
The problem for conservatives is that making sure poor people have health insurance is politically popular, at least in the abstract. But the plans that achieve it tend to be in tension with both broad tenets of conservatism — they raise taxes, it redistribute wealth, regulate insurers, and grow the government — and with key factions of the conservative coalition.
Health reform turns out to have a liberal bias.
Republicans only care about health reform when Democrats make them
The need to develop and support an alternative to whatever Democrats were proposing has led Republicans, including many conservatives, to back plans they later regret. In the 1990s, for instance, the main Republican alternative to President Bill Clinton's reforms paired regulations on insurers with subsidies for the poor and an individual mandate to force participation by the healthy. Sound familiar?
The bill ultimately failed, but it inspired the Massachusetts health reforms passed by then-Governor Mitt Romney, which in turn inspired Obamacare.
For today's GOP, Klein says, "the elusive goal of repealing [Obamacare] has been the driving force behind Republican politics." It is ironic that the law Republicans loathe most is actually based on ideas they developed, and that their most recent presidential nominee actually implemented.
But it makes more sense if you take Klein's belief that conservatives don't care much about health reform and pair it with Cannon's insight that trying to provide everyone with health insurance is a fundamentally liberal project: the initial adoption of the alternative ideas was largely cynical — it was there to weaken support for Clinton's proposal, not become law — and the kinds of health-reform plans that resonate with the public and are viable alternatives to Democratic ideas will always, in the end, repel conservatives.
This is, fundamentally, the difference between the Democratic Party and the Republican Party on health-care reform. Democrats cared so much about health reform that they based their work on a plan Republicans came up with in order to give themselves a better chance of success. Republicans care so little about health reform that they haven't even bothered to choose one of their own plans to unite behind, much less made any painful ideological concessions to clear a path to passage.
The loneliness of the conservative health wonk
Klein's book makes clear, perhaps accidentally, that the real fight in the Republican Party isn't between health wonks who favor different plans. It's between those in the party who want to prioritize health reform and those who don't. And time and again, those who don't want to prioritize uniting around a health plan win the fight. It's five years after Obamacare, and we are still waiting for the Republican Party's leadership to propose detailed replacement plan.
It's not as if they haven't needed one, or promised one, or even set themselves deadlines for unveiling one. But as Peter Suderman, another smart health-care voice on the right, says, they haven't been able to deliver:
In March, Rep. Paul Ryan (R-Wisc.), the Republican Chairman of the House Ways and Means Committee, promised that he would have a bill ready and scored by the Congressional Budget Office by late June when the decision arrived. "We have to be prepared, by the time the ruling comes, to have something. Not months later," he said. Yet when Ryan finally unveiled the outlines of a plan last Wednesday, he provided few details, and no legislation or CBO score.
The story is similar in the Senate. In March, GOP senators John Barasso, Lamar Alexander and Orrin Hatch (R-Utah) announced in The Washington Post that they were ready with "a plan to create a bridge away from Obamacare." The workings of the plan had been widely discussed, the op-ed declared, and "there is a great deal of consensus on how to proceed."
But after a briefing for Republican Senators last week, two other Republican Senators—Lindsey Graham and John Cornyn—said flatly that there was no consensus about what to do.
Suderman concludes: "The GOP plan is always in development but never ready for final release."
That's not an accident. Health reform isn't rocket science. The various options are reasonably well-known. The various paths are pretty clear. There are dozens, perhaps hundreds, of fully formed plans laying around in think tanks and congressional offices. But whenever Republicans decide to settle on one, they ultimately flinch, and for good reason.
The terrible politics of health reform
Health reform is an incredibly tough, painful project. Everything you do has tradeoffs, some of them awful.
In the book, many of Klein's interlocutors focus on Obamacare's regulation that exchange insurance can only charge older applicants three times as much as younger applicants. This raises prices for the young.
"If you really want to make a dent in the uninsured population," says Avik Roy, a health scholar at the Manhattan Institute, "the goal shouldn’t be to make insurance more expensive for young people. It should be to make insurance less expensive for young people."
His plan would allow insurers to charge older applicants six times more than younger applicants. And he's right: that would make health care cheaper for younger applicants, and it would mean more of them get insured. But it would also make health insurance more expensive for older applicants, who often need the insurance more desperately. This is a hard, ugly choice, not an easy one — and it's likely to be an unpopular choice with the older voters who are most loyal to the Republican Party.
Some of the provisions in the conservative replacement plans will be wildly unpopular. Many of them try to sharply curtail the tax preference employers get to offer insurance. Louisiana Governor Bobby Jindal, for instance, converts it into a standard deduction for anyone — employed or not. The problem is the deduction is worth much less than many of the plans employers currently offer. It would, overnight, make some of the most generous plans offered by employers completely unaffordable. This sounds like a good idea to many health wonks, including me. We shouldn't be offering unique subsidies to employer-provided insurance, and we definitely shouldn't be making those subsidies unlimited in their scope. But it's political death.
It is, in fact, an echo of a plan Sen. John McCain proposed in the 2008 election. That plan was such a gaping vulnerability that, as Klein notes, the Obama campaign's attack ad against it stands as the single most widely aired attack ad of the last decade. (The Obama administration later took a modest, and hypocritical, step toward curtailing the deductibility of pricey employer plans with Obamacare's excise tax.)
That ad is a reminder that while Republicans have spent the last four years attacking Obamacare for its tough tradeoffs and unpopular decisions, the moment they begin pushing a serious alternative, they'll suddenly have to deal with Democrats doing the same to them. And Democrats will be doing it from the higher ground of the post-Obamacare world: there will be millions and millions of people getting health insurance from the very program Republicans want to destroy, and every single one of them will be a possible story to use in an attack ad.
If a Republican wins the White House in 2016, they'll have to decide whether to spend their precious political capital repealing and replacing Obamacare. Imagine Jeb Bush is being inaugurated in January 2017. Is he really going to want to spend his first year on health reform rather than education? Does he want to begin his presidency by upending health insurance for 20 million people? Does he really want the endless negotiations with the insurance companies and pharmaceutical companies and hospital lobbies and Medicaid advocates?
In his Thursday column, Klein warns that "if Republicans go back to hibernation mode on healthcare after this decision, it will guarantee that the next round of reform will once again wait until Democrats can reclaim power." But that is, on some level, what Republicans want. They are happy to let health reform be the Democrats' problem, even if they are not happy with the kinds of solutions Democrats pass.