The Strange Persistence Of Conservative Health Care Ideas

health care reform, obamacare, supreme court
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Matt Yglesias patiently read through the National Review’s latest prescription for a conservative alternative to the Affordable Care Act, and here’s what he found.

The core of a replacement would be a change in the tax treatment of health insurance. The tax break for coverage would be flattened and capped so that people would not get a bigger break the more comprehensive their insurance. The break would also be extended to people who do not have access to employer coverage. People would be allowed to purchase health insurance across state lines. Medicaid and Medicare would be converted into subsidies–essentially add-ons to the tax break or credit for coverage–for people to buy private coverage and pay for out-of-pocket health expenses.

Matt also did the yeoman’s work of explaining for the umpteenth time why these ideas won’t work. But what I’m interested in is how persistent this particular conservative fixation is.

We know that Republican elected officials have been unyielding about their economic agenda since the election. But Step off of Capitol Hill and smart conservatives are spelling out ideas that both adhere to their ideological precepts and address the needs of poor and middle class people…. just not when it comes health care. Health care seems to be the one issue where, when challenged, smart conservatives scratch their heads for a while, then say “A ha!” and rattle off the same ideas they’ve backed for years, hoping nobody notices.

A big part of the reason, I think, is that their four year campaign against the Affordable Care Act has made it difficult for them to support proposals that incorporate key features of Obamacare. No universality, no addressing spending through price controls.

The closest thing to an exception is this proposal, by Doug Holtz-Eakin and Avik Roy, which they bill as a series of conservative reforms to the Affordable Care Act. But on closer inspection, it looks an awful lot like a plan to devolve Obamacare backwards toward the conservative ideal described above.

First, eliminate “community rating,” the pooling mechanism that along with the individual mandate makes the ban on discrimination against people with pre-existing conditions workable. Take away community rating, and you have universal insurance that only healthy people can afford. That would increase demand for the high-risk pools at the heart of the conservative reform plan. Check. Second, further means test the subsidies, and reduce their growth rate, before, third, folding Medicare and Medicaid into the exchanges, making them subsidy plans. Check.

It should go without saying but a big point of Obamacare was to create a single program for people who neither qualify for Medicare, Medicaid or employer sponsored insurance, and none of those systems make separate pools for healthy and sick people. Democrats might have reluctantly supported the latter elements in exchange for GOP votes for universality — but the time for the right to push that compromise was in 2009. In 2013 it’s time for fresh thinking.

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