Now that HealthCare.Gov is on a clear path to functionality, Republicans are having to come to terms with the fact that Obamacare will not conveniently collapse before anyone can purchase insurance. If the law is going to fulfill its promise of destroying Barack Obama's presidency and giving Republicans their long-awaited chance to repeal-and-replace, it will have to be because people actually hate the insurance they get through Obamacare.
Republicans have zeroed in on two things that people really will hate about insurance under Obamacare: The high deductibles and the limited networks. Brendan Buck, press secretary for House Speaker John Boehner, tweets:
"As consumers dig into the details," Robert Pear reports in the linked article, "they are finding that the deductibles and other out-of-pocket costs are often much higher than what is typical in employer-sponsored health plans."
What's confusing about this line of attack is that high-deductible health-care plans -- more commonly known as "health savings accounts" -- were, before Obamacare, a core tenet of Republican health-care policy thinking. In fact, one of the major criticisms of Obamacare was that it would somehow kill those plans off. "Obamacare may be fatal for your HSA," warned the Heritage Foundation on 2010. "Health Savings Accounts Under Attack" blared Red State.
When Republicans were forced to come up with alternatives for Obamacare, high-deductible plans were core to those proposals. "Conservatives have suggested deregulating Obamacare’s exchanges to make it easier to provide policies with high deductibles," wrote Ramesh Ponnuru. One of those conservatives was right-wing darling Dr. Ben Carson. "In order to right the ship, we need to return the responsibility for good health care to the patient and the health care provider," he said. "One of the best ways to do this is through health savings accounts, which patients can control."
This always baffled Obamacare's supporters. "The minimal, or bronze, insurance option allows out-of-pocket spending of up to $12,500 for a family of four," wrote Jonathan Cohn. "Those are some pretty high deductibles!"
Now that those high deductibles are here, Republicans have decided that they are, if anything, too high. Just one more broken promise.
Obama's pledge that "if you like your doctor, you can keep your doctor" is also under fire. The issue here is that insurers entering the competitive health marketplaces are tightening their networks in order to cut costs and improve quality. It's worked: Premiums in the marketplaces are far lower than was expected when Obamacare passed.
This, too, is a success for a longtime conservative health-policy idea. Insurance exchanges have been in every major Republican health-care bill since the early 1990s. They were in Paul Ryan's 2009 health-care proposal. They're the basis of the GOP's plan for Medicare reform.
Conservatives believe that a huge problem with the health-care status quo is that most people get insurance through their employer or the government. In both cases, they don't directly pay the full cost of the plan, and so they have every reason to demand more generous care rather than more cost-effective care. If they were paying and shopping for plans themselves, they would care about price, and insurers would have an incentive to cut costs by carefully choosing the doctors and hospitals that can do the best job for the least money.
"Narrow networks are not some cruel attempt to limit patient choice foisted upon us by the insurance industry," write economists David Dranove and Craig Garthwaite. "Instead, these plans may provide our best opportunity for harnessing market forces to lower prices."
But Republicans don't seem pleased to see their ideas in action. "As I travel across Kentucky, I hear from many constituents who are seeing premiums increase along with higher co-pays and higher deductibles as a result of Obamacare," wrote Mitch McConnell in an op-ed for the New Democrat Leader. "Adding insult to injury, these constituents are discovering that despite these higher costs, they have no guarantee that they will be able to continue using the hospital of their choice." How dare Democrats implement these policies Republicans have been pushing for years!
The Republican turnaround on high-deductible plans and tighter networks has puzzled many longtime health-care observers. "Conservatives are winning at least as much as they are losing in health care, even if they don’t know it or won’t say it," wrote Drew Altman, president of the Kaiser Family Foundation.
I asked some of the GOP's most influential health-care voices about the tension between the criticisms Republicans are launching against Obamacare and their longstanding commitment to these ideas.
One common response I got was that it's fair to criticize President Obama's broken promises even if the underlying policies are desirable. Project HOPE's Gail Wilensky, for instance, agreed that "similar types of effects are likely to result with any premium support plan, including Ryan’s." But she went on to say that "the major difference is that presumably Ryan would not have been so foolish as to say 'if you like your health plan, you can keep your health plan' and 'if you like your doctor, you can keep your doctor'. Those were promises that were predictably beyond the President’s power to make at the moment he made them and people like me were saying so at the time they were being made."
Another answer was that Republicans believe that Obamacare is giving policies they otherwise like a bad name. "Giving consumers the choice of narrower physician networks and higher deductibles, in exchange for lower premiums, is a good thing," e-mails the Manhattan Institute's Avik Roy. "The problem with Obamacare is that people are trading narrower networks and higher deductibles for higher premiums. And that’s because of all the other stuff that Obamacare does to the insurance market."
The problem, in other words, isn't the higher deductibles and the tighter networks -- it's all the other stuff. In that case, it's weird Republicans are focusing on the higher deductibles and tighter networks.
The GOP's problem is that the "other stuff Obamacare does to the insurance market" is wildly popular. Roy is right that the ban on discrimination against preexisting conditions, the limits on age discrimination, the elimination of lifetime caps, and related policies raise the costs of insurance. But Republicans don't want to oppose any of that directly.
This gets to a truth about Republican health-care policy ideas, which is that many of them are horrendously unpopular. That's not because they're bad ideas. There's a lot of merit to eliminating the tax break for employer-provided insurance and increasing deductibles on most insurance plans. But no one likes hearing that they should pay more out-of-pocket for health care. No one likes hearing that their plan is going to be among the ones canceled by newly cost-sensitive employers.
One option was for Republicans to build as many of their ideas into the Affordable Care Act and force Democrats to take partial responsibility for these hideously unpopular, but fairly reasonable, ideas. They didn't do that. Then Democrats picked some of the ideas up anyway. So Republicans again had a chance to focus their fire on the parts of the law they hated -- like the Medicaid expansion -- in the hopes of moving the health-care system in the direction they prefer. Instead, they're aiming at the least popular policies in the law -- which just so happen to also be the exactly policies that they support.
We'll see whether Obamacare withstands the onslaught. But either way, once the assault is over, what kind of health policy will Republicans be left with? How can they propose anything that will cancel plans or raise deductibles or tighten networks? How can they propose anything at all?