August 20, 2013

We’re hearing more and more rumblings from top Republicans that the GOP’s current position on Obamacare is untenable — that the party can’t continue to call for the destruction of Obamacare forever without offering any alternative. The push from the right for a shutdown has only drawn that into sharper relief, and so we’re finally hearing that Republicans — finally! — will make good on their promise, now 30 months overdue, to come up with the “replace” part of repeal-and-replace.

It ain’t gonna happen. There won’t be any serious GOP alternative to Obamacare.

The first problem with developing an alternative to the Affordable Care Act is that there just may not be any policy alternative that comes close to accomplishing what the law accomplishes. At first, it looked like conservatives would leave themselves a way to propose their own version of the same reforms in Obamacare, and rename it on their own terms. As such, there seemed to be a method to it when, at the outset, conservatives worked hard to prevent an actual discussion of the substance of the law itself. Much of the initial hatred of the ACA was focused on a series of phony talking points and outright lies (“government takeover” of health care; “death panels”; the law was “rammed through” using corrupt procedural tricks; etc.).

Since none of that was true, it gave Republicans an opening: they may have stigmatized “Obamacare,” but they hadn’t stigmatized the policy ideas at the core of the law — the combination of exchanges and subsidies that actually started out as a Republican plan, as Ezra Klein explains in detail today. In other words, as late as 2012 it seemed plausible Republicans could choose to invent a ConservaCare proposal based on Ronald Reagan Marketplaces that would basically offer a slightly different spin on the same underlying idea.

But conservatives have decided that no policy overlap with Obamacare is acceptable. Tea Partiers have chosen to oppose not only Obamacare but any policy which even faintly resembles any piece of that omnibus legislation. We saw this in the House defeat of Eric Cantor’s high-risk poll bill this spring, when conservatives revolted against his effort to propose a GOP plan protecting those with preexisting conditions.

But that refusal to accept any of the substance of Obamacare has run Republicans right into a brick wall. Thanks to the way that the ACA was put together — it really is a mammoth omnibus bill which incorporated practically every plausible policy idea out there — it turns out that practically everything you can do to provide health insurance is now tainted by Obamacare.

And that’s left Republicans with only one remaining option: turning against the whole concept of health insurance itself. Ed Kilgore accurately describes this mindset:

A growing tendency to oppose the very idea of redistribution of risk and cost, which is essential not just to public health reform efforts, but to private health insurance. Conservatives often seem to want to go back to those days when patients paid doctors with cash or did without health care altogether. That’s “personal responsibility” with a vengeance.

That’s right. See, for example, Philip Klein this morning arguing that in the exchanges “purchasing health insurance, in aggregate, is a bad deal for younger Americans.” Well, yes, but only in the sense that purchasing any kind of private insurance, in aggregate, is always going to have a negative expected value. Otherwise no one could make profits from selling it!

In practice, this has meant a conservative fixation on the supposedly bad deal Obamacare offers “young healthies,” who serious conservatives such as Klein and Ross Douthat have argued should only want catastrophic insurance, while conservative activists have taken to arguing should they go without insurance altogether.

That’s the logical endpoint, isn’t it? If everything — even the whole concept of insurance — is tainted by association with Obamacare, then the only safe ground for conservatives (safe, that is, from cries of “RINO”) is to oppose insurance altogether. After all, as Ezra Klein notes, “plausible health-care plans are hard to come by.” So it’s not as if the leap to opposing the concept of insurance is leaving anything obvious behind.

There’s simply no way to construct a real, workable health care reform plan that (1) is based on private insurance, and (2) avoids any of the elements of the Affordable Care Act. There just isn’t any policy space there. Since Republicans aren’t going to embrace public insurance as an alternative, that’s leaving them increasingly ready to oppose any kind of insurance at all. That makes a straight Obamacare repeal a seemingly logical option; there’s no reason to replace it, since there’s no point in public policy designed to share risk. And as a bonus: if insurance itself is a bad thing, or at least not something essential, then it’s not really a disaster that repealing Obamacare would leave millions without insurance.

Unfortunately for Republicans, what they wind up with is a policy alternative that most Americans would want nothing to do with.