Ross Douthat writes:
The G.O.P. remains the most plausible institutional vehicle for conservative ideas about health care, and Republican politicians are (for the most part) the only political figures capable of delivering the kind of reforms that right-of-center wonks and commentators want.
The fact of the matter is that the key policy ideas that reigned over conservative health-care policy thinking from 1989 to 2009 are included in the Affordable Care Act. These include, but are not limited to, the individual mandate, health insurance exchanges, price transparency in the provider and insurance markets, limiting the tax preference for employer-sponsored health care, and transitioning the system in general -- and Medicare in particular -- away from fee-for-service payments.
Moreover, if even a handful of Republicans had been willing to cut a deal on the Affordable Care Act, the Obama administration would have given them the moon in return. There was, for instance, a desire to go much further on limiting the tax preference for employer-sponsored health care and a willingness to go much further on medical malpractice reform. But Democrats couldn't do either thing without Republicans willing to make those policies a necessary compromise that led to Republican votes rather than a preemptive concession, and no Republicans were willing to give them cover.
Even so, in the end, President Obama's health-care plan did not look like Bill Clinton's health-care plan or Ted Kennedy's health-care plan or Harry Truman's health-care plan. It looked like Republican Sen. John Chafee's health-care plan. The one that he brought out, with Republican Senate Majority Leader Bob Dole's support, in 1993. The one that was the product of three years of work by the Senate Republican health-care task force. The one that ended up inspiring Mitt Romney's health-care proposal in Massachusetts. In other words, as Andrew Sullivan pithily puts it:
The truth is that "the most plausible institutional vehicle for conservative ideas about health care" is the Obama administration.
Of course, the problem is that once the Obama administration adopts those ideas, conservatives cease to see them as conservative ideas. But that's part of why the Republican Party hasn't been a very plausible institutional vehicle for health-care reform: The GOP isn't as committed to its particular ideas on health-care policy as it is to other issues and to regaining power. And so when given control of the government, it doesn't choose to focus on health-care reform, and when out of power and given an opportunity to make policy gains by compromising with Democrats, it spurns their offers.
Think this will be different under Mitt Romney? Well, House Republicans continue to fail in their efforts to come up with a "replace" agenda, and Senate Republicans are led by Mitch McConnell, who just gave this interview to the National Review's Robert Costa:
Over the weekend, you and Chris Wallace of Fox News had an exchange about the uninsured, where you said that’s “not the issue.” What did you mean by that? And what is your preferred policy for covering more of the uninsured?
Our goal, number one, is to repeal and replace Obamacare. Number two, is to address the health care that the federal government has already got, which is in deep trouble, both Medicare and Medicaid. Earlier today I saw that 15 governors have now said that they’re going to opt out of the additional Medicaid mandate, now that the Supreme Court has made it clear that they have the option to do so. I think we will be looking at every angle to replace this, and what it’s replaced with, of course, depends on what the market looks like at that time. For example, the private health-insurance market has already responded on the growing demand to leave 26-year-olds on policies, because it’s turning out to be a good business decision for them. The issue of preexisting conditions has always been complex. Half of the states are addressing that with high-risk pools. I’m not convinced that issue needs to be addressed at the federal level. We will see. But job one is to replace Obamacare in its entirety, clean up the health care we’re already responsible for, and then we’ll see where we go from there.
If Obama is reelected, it is likely that he will want to cut a deal with Republicans to get their buy-in on the Affordable Care Act before it goes into effect in 2014. If Romney is elected, well, as McConnell says, "we'll see where we go from there," but I'm betting it's not toward comprehensive health care reform. So, if you're looking for anything beyond cutting spending on Medicare and Medicaid, the Obama administration probably remains the most plausible institutional vehicle for conservative ideas about reforming the broader health-care system.