“Success and failure often feel exactly the same.” The best sentence I read today on the repeal debate comes from Yuval Levin’s new piece at National Review, which is exceptionally helpful in understanding the current state of the Republican Obamacare repeal efforts. Things feel hectic and uncertain right now, he argues, not because repeal is failing but because policymaking is always hectic and uncertain. The first sentence of this paragraph, in particular, is so important to remember as we start a very lengthy policy debate:
One lesson I’ve learned from working on public policy in and out of government is that in a complex legislative debate, success and failure often feel exactly the same while they are happening. They both feel pretty much like pandemonium. During the lengthy period when some basic questions of strategy and substance are still open, everything seems up for grabs and the entire edifice always looks on the edge of collapsing. So it is not easy to judge the prospects for success by orderliness or discipline along the way.
Levin’s assessment of where Republicans are now on repeal and replace reminds me a lot of where Democrats were in 2009, at the start of the original Obamacare debate. There were dozens of moments where it legitimately seemed like Democrats would fail at their health overhaul effort — moments when Sen. Joe Lieberman, for example, would demand no public option, or pro-life House Democrats would balk at the possibility of government subsidies going toward abortion.
There were moments when then-House Speaker Nancy Pelosi said she didn’t have the votes to pass the Senate bill. (I know because back in 2009, I was writing about it!) Around the same time, my now-colleague Ezra Klein wondered in a headline, “Did Nancy Pelosi just declare health care dead?”
There were so many times that I and others wondered: Will Democrats really pull this thing off? Is the health care effort about to fail? In the end, Democrats did have a critical mass willing to support the final package. But for most of the debate, it was incredibly hard to tell success from failure.
This is where we are right now in the new health care debate. It’s an opening, messy part of policymaking where nobody quite knows what will happen next.
“We are very early in the process ... and ample opportunity remains for Republicans in Congress to correct their course as they go,” Levin writes. “That course will inevitably change several times before the story ends.”
Does Trump actually have a health care plan?
Levin’s piece is great at providing some big-picture framing to the health care debate. But it also has one specific detail worth pausing on: There is skepticism, even within the Trump transition team, that the president-elect has actually drafted the health care plan he described to the Washington Post.
“After Trump’s Washington Post interview this past Sunday, the conservative health-care universe, including some people on Trump’s own team, quickly concluded that the separate administration plan he described was entirely a figment of Trump’s imagination,” Levin writes.
An additional piece of evidence for Levin’s claim: Trump has since changed his mind about how his plan would work, using an interview Wednesday morning with Axios to, according to its report, “back-track a bit from his promise of insurance for everybody.”
This moment in Price’s hearing demonstrates a key tension in Republican health policy
Price now talking about patients forgoing care because of high deductibles, a few minutes after mentioning merits of HDHPs/HSAs— Adrianna McIntyre (@onceuponA) January 18, 2017
Harvard University’s Adrianna McIntyre notes an interesting tension in the answers provided by Rep. Tom Price during his Wednesday morning confirmation hearing for health and human services secretary. Price went from bemoaning high out-of-pocket costs to, within minutes, talking about the benefits of high-deductible plans.
High-deductible plans, of course, have quite high out-of-pocket costs — they cause people to forgo care because of the cost. And that is a feature, not a bug. The whole point of deductibles is to tamp down overall health spending by putting some of the cost on consumers. This “skin in the game,” as health wonks like to say, should make people think twice about whether they really need that doctor’s visit.
There is a clear and legitimate policy case for high-deductible plans. There is good evidence that people really do use their insurance less when they have to pay more. But make no mistake: High-deductible insurance (and the Republican plans that feature these ideas prominently) won’t fix complaints about high out-of-pocket costs — and stand a decent chance of making those complaints even more widespread.
Conservatives have long promoted high deductibles as a way of controlling costs. It's a legitimate position, but not a populist one. https://t.co/7g251rOimm— Larry Levitt (@larry_levitt) January 18, 2017
Kliff’s notes: today’s top three health policy reads
“Republican senator would let states keep Obamacare if they want”: “A doctor who worked for decades in charity hospitals and clinics before joining Congress, [Sen. Bill] Cassidy plans to introduce soon an updated version of his health-care plan aimed at giving states flexibility to keep Obamacare, nix it entirely or transition to a new system of health savings accounts and automatic health plan enrollment.”
“Repeal and replace: words still hanging over G.O.P health care strategy”: “Many conservatives were simply advocating a vow to repeal the new law, but Republican strategists worried that pressing for repeal without an alternative could backfire. So they batted around a few ideas before Josh Holmes, then a top communications adviser to Mr. [Mitch] McConnell, tossed out the nicely alliterative phrase ‘repeal and replace.’ That seemed to do the job, with its promise to get rid of the new law detested by Republicans while suggesting that something better would follow.”
“I voted for Trump, and I already regret it”: “In the end, I voted for Trump because he promised to repeal and replace Obamacare, and that was the most important issue to my own life. Looking back, I realize what a mistake it was. I ignored the pundits who repeated over and over again that he would not follow through on his promises, thinking they were spewing hysterics for better ratings. Sitting on my couch, my mouth agape at the words coming out his mouth on the TV before me, I realized just how wrong I was.”