On Tuesday, Marco Rubio and Scott Walker released their health-care plans. In doing so, they showed the problems that years of opportunistic attacks on Obamacare will create for any future Republican president who wants to reform the health-care system.
There's always been much for Republicans to oppose in Obamacare. The law, at its core, raises taxes on the rich to give money to the poor. It adds layers and layers of regulation to the insurance industry. It creates a fundamental expectation that the federal government will make affordable insurance available for anyone who wants to purchase it.
The problem for Republicans has always been that these aspects of Obamacare are popular.
And so the GOP, in its zeal to destroy the law, focused on the parts that were unpopular. Obamacare canceled existing insurance plans, raised premiums for certain groups of people, and pushed families to purchase insurance with high deductibles and narrow networks.
Republicans were right — these are real vulnerabilities in the law. The problem is that they're real vulnerabilities in all of the Republican plans, too.
The result is that Republicans have left themselves in a dangerous political space: In order to repeal and replace Obamacare, they're going to have to do everything they criticized Obamacare for doing.
If you like your insurance, you may not be able to keep it
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"You have people out there," Marco Rubio said in 2013, "that found a plan they could afford and that covered what they wanted to have covered. They were happy with their plan. It wasn’t perfect. It didn’t have everything. But it was what they could afford, and it was okay and good for them. And they were told that they would be able to keep that, but the Obama Administration knew all along that wasn’t true."
Rubio was blistering on this point. He even sponsored legislation called the "If You Like Your Health Care Plan, You Can Keep It Act."
But under Rubiocare, even if you like your health-care plan, there's no guarantee you'll be able to keep it.
Though the details of Rubio's plan remain vague, the broad strokes reveal a few policy changes that will inevitably mean millions of people lose the health insurance they currently have.
Rubio repeals Obamacare's subsides and replaces them with "an advanceable, refundable tax credit that all Americans can use to purchase health insurance." At the same time, he wants to put "the tax preference for employer-sponsored insurance on a glide path to ensure that it will equal the level of the credits within a decade."
In other words, Rubio's subsidy scheme is standardized and universal rather than, as in Obamacare, targeted and highly progressive. And in order to pay for the cost of providing subsidies to everyone, the unlimited subsidy that currently exists for employer-provided tax insurance will become much, much more limited.
That means a lot of poor people who use Obamacare's subsidies to purchase comprehensive insurance will be forced to give up that insurance and purchase a leaner plan. At the same time, employers who take advantage of the tax break to offer generous insurance now will have to move their employees onto cheaper plans.
Similarly, Rubio intends to transform Medicaid and Medicare by turning the former into a per-capita block grant system and the latter into a premium support system. In both cases, the result would be that people who like their insurance now would find they can no longer afford it, or, in the case of Medicaid, that it's no longer being offered at all.
Scott Walker's premium spikes
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Day to day, most conservative criticism of Obamacare is about how much people have to pay for their plans. Take Scott Walker, who writes, "Rather than out-of-control premium increases, my plan will actually make health care more affordable for everyone."
But it won't. Not even close.
Walker's plan does something very unusual: Rather than basing tax credits on income, as Obamacare does, it bases tax credits on age. The implications of this are bizarre. As Sarah Kliff writes, "Under Walker's plan, Taylor Swift would get $1,200 to help buy coverage because she's 25, while Obamacare would give her nothing on the grounds that she's superrich."
But it also means that premiums are going to spike for poor people currently relying on Obamacare's progressive subsidies.
Similarly, Walker promises that his plan would "protect all Americans with pre-existing conditions." But it wouldn't. If you want to protect all Americans with preexisting conditions, you need to force insurers to sell to them at affordable prices. But if you're going to do that, then you need to make sure young and healthy people buy insurance so average premiums remain low. And if you're going to do that, then you need subsidies to make that insurance a good deal for young and healthy people, as they're often poor.
And if you do all that, then, whoops, you've just reinvented Obamacare.
So Walker's plan doesn't protect everyone with preexisting conditions. It only protects people who have had "continuous coverage" — which is to say, people who have never fallen uninsured. But a lot of people fall uninsured for short periods of time — one study found that between 2004 and 2007, 89 million Americans had at least a one-month lapse in coverage.
For those people, Walker gestures toward high-risk pools — an idea that's failed basically wherever it's been tried, and would, at any rate, mean that people with preexisting conditions and previous lapses in coverage would potentially lose the coverage they have now and would definitely lose the broad set of choices for coverage they would have had under Obamacare.
Higher deductibles, narrower networks
Another common — and telling — complaint about Obamacare is that the health insurance people are buying on the exchanges is barely insurance at all. "What good is insurance if you can’t find a doctor or it doesn’t pay a penny until you’ve paid your huge deductible?" asks the conservative website HotAir.
But both Rubio and Walker's plans would hasten the trend toward high deductibles, narrow networks, and sparse coverage.
Both promise to lift various regulations Obamacare places on insurers — and though neither plan is specific about which regulations will be lifted, it's safe to assume that it will be some combination of the regulations limiting deductibles and out-of-pocket spending and the regulations forcing insurers to cover a wide range of services.
Meanwhile, both plans look to give a large number of Americans a modest tax credit to purchase insurance, rather than, as Obamacare does, giving a smaller number of poorer Americans a larger tax credit to purchase insurance.
The result of these two policy approaches is obvious: Insurers will be able to offer leaner coverage that shifts more risk to the buyer, and buyers will be incentivized to choose cheaper insurance that doesn't force them to pay out of pocket to cover subsidies.
These are the exact same forces that have led to the popularity of high-deductible, narrow-network plans in Obamacare, but Walker and Rubio are proposing to supercharge them.
Why the next Republican president isn't going to repeal and replace Obamacare
You can argue the policy merits of all these ideas. I think, for instance, that Rubio's effort to equalize the tax treatment of employer and non-employer health insurance is sound. But what's inarguable is that these plans create the same kinds of problems Republicans assailed in Obamacare.
Is a party that brutalized Obamacare for taking insurance away from people who were happy with what they had really going to become the party that takes insurance away from millions of people who are happy with what they have? Is a party that attacked Obamacare for raising premiums on people really going to raise premiums for millions?
This is the difficult position Republicans have left themselves in. Their condemnations of Obamacare were so total, so sweeping, and so opportunistic that they're now on record against policies they would otherwise support and outcomes that are inevitable if they try to change the system.
This is why I don't believe the next Republican president really will try to repeal and replace Obamacare.
Republicans have spent the past four years attacking Obamacare for its tough trade-offs and unpopular decisions, but 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, he or she will have to decide whether to spend precious political capital repealing and replacing Obamacare. Imagine Marco Rubio is being inaugurated in January 2017. Is he really going to want to spend his first year on health reform rather than higher education? Does he want to begin his presidency by upending health insurance for 20 million people? Does he want to deal with the ads that will come when he tries to cut Medicare spending? Does he really want to be held accountable when employers begin cutting their health benefits and blaming "Rubiocare"?
I doubt it. Republicans have put themselves in a no-win position on health care. And so the next GOP president is probably going to decide it's better just not to play.
