In the last few days, Scott Walker and Marco Rubio released health care plans, and other Republican candidates are sure to follow soon. Most will probably be pretty similar, even if some are more fully fleshed out than others.
But they’ll all share one feature, the thing that tells you that they aren’t even remotely serious about this issue: they will take as their starting point that the entire Affordable Care Act should be repealed.
I say that that shows they aren’t serious not because I think the ACA has done a great deal of good, though I do think that. I say it because it shows that they’re completely unwilling to grapple with both the health care system as it exists today, and how incredibly disruptive the wholesale changes they’re proposing would be. Walker’s plan even says, “unlike the disruption caused by ObamaCare, my plan would allow for a smooth, easy transition into a better health care system.” This is the health care equivalent of thinking the Iraq War would be a cakewalk.
The reality is that repealing the ACA now that it has been implemented would mean a complete and utter transformation of American health care. Republicans have often lamented that the law was so terribly long and included many different rules and regulations — yet now they act as though the law amounts to just a couple of rules here and there that can therefore be tossed out without too much trouble. But they were right the first time: the law is indeed complex, and has brought hundreds of changes big and small to American health care, not just in how people get insurance but in how Medicare and Medicaid work, how doctors and hospitals are paid, and in all sorts of other areas.
The ACA established health care exchanges. It brought millions of people into Medicaid, it closed the Medicare prescription drug “doughnut hole.” It gave subsidies to small businesses. It funded pilot projects to explore new means of providing and paying for care, it imposed new regulations on insurance companies. It created new wellness and preventive care programs, it provided new funding for community health centers. It did all that, and much more. You can argue that each one of these was a good or a bad idea, but you can’t pretend that unwinding them all would be anything resembling a “smooth, easy transition.”
We know why every Republican health care plan has to start with repealing the ACA: politics. Republicans have spent the last five years telling their constituents that they’re going to repeal it any day now, and they’ve held over 50 repeal votes in Congress. They’ve refused to admit that a word of it has any merit, even as they try to incorporate some of its more popular reforms (like protections for people with pre-existing conditions) into their own plans. So they’ve backed themselves into a corner where whatever any Republican offers has to start with repeal.
Which is why all their plans, the ones that have been released and the ones yet to come, are absurdly unrealistic. They pretend that it will be no problem to completely transform the American health care system — and there will be no losers in such a transformation, only winners — which shows that they have no intention of actually doing so. In fact, I’d go so far as to say that if a Republican gets elected next November, he’ll be relieved when his health care plan dies in Congress.
Let’s contrast that with how Democrats acted in 2008, when there was a vigorous debate in the presidential primary over health care. The three leading candidates, Barack Obama, Hillary Clinton, and John Edwards, all had very similar plans, similar because they reflected the Democratic consensus on health care reform that had evolved in the decade and a half since Bill Clinton’s reform effort failed. One major disagreement was over whether there had to be an individual mandate — Clinton’s plan had one, and Obama’s didn’t — but when he took office, Obama accepted that the mandate was necessary to make the entire plan work. It wasn’t a fantasy plan that just pandered to liberal hopes, it was something that could actually pass and be implemented.
Whenever liberals told Obama that a single-payer health plan would be far superior to what he was proposing, he would respond that if we were starting from scratch, that would probably be true. But, he’d say, we aren’t starting from scratch, so the ACA has to accommodate itself to the health care system that already exists. The result was a gigantic kludge, new complexity layered on top of an already complex system in an attempt to solve its varied shortcomings. Like all kludges, it seemed like the realistic option given the situation we confronted, but it left us with something that was far from perfect.
A Republican who actually wanted to pass real health care reform would have to approach the problem the same way: by saying that for better or worse, the Affordable Care Act has already affected the system in profound ways, so any realistic plan has to understand what those changes are, and find the most efficient way to keep the ones that are working and change the ones that aren’t. That doesn’t mean that repeal is impossible, just that it would be a spectacular upheaval, one that I promise you Republicans have no genuine appetite for. Remember all the screaming and shouting they did over the people on the individual market whose previous plans didn’t qualify under the new regulations, and who had to shop for new plans? Multiply that by ten or twenty times, because that’s how many people would likely lose their existing coverage if you repealed the ACA in one fell swoop.
And that would be only the beginning. So when any Republican candidate says he or she has a plan to reform health care, take a close look. If it starts with repealing the ACA — and it will — then you’ll know it isn’t serious and it’s never going to happen.