From the moment President Obama set out to reform the health-care system, Republican opposition was a Terminator robot driven by a boundless, remorseless determination to kill. Every single Republican in Congress opposed the bill, and Republicans who even considered supporting something vaguely like it were ruthlessly purged. Even after it was passed, Republicans ginned up far-fetched legal challenges, held endless votes to repeal it, and vowed not to implement it at the state level. They couldn't be bargained with, couldn't be reasoned with, and felt no pity.
The repeal machine has suffered a series of devastating blows — the Supreme Court upholding the individual mandate, Obama’s reelection, the decision of several Republican governors to accept the program’s expansion of Medicaid — and continued to lurch forward. But Governor Rick Scott’s announcement that he will enroll uninsured Floridians in Medicaid appears to be a real death blow, the moment the cyborg’s head is crushed in a steel press.
From the moment he appeared on the national stage, Scott seemed to be engineered to fight health-care reform. The wealthy owner of a vast hospital chain that paid massive fines for overbilling Medicare during his tenure, Scott bankrolled an anti-reform lobby, then ran and won in 2010 on a platform of obsessive opposition to Obamacare. He has steadfastly vowed to turn down federal subsidies to cover his state’s uninsured, and even concocted phony accounting assumptions to justify his stance. Rick Scott really hates health-care reform.
But Scott is a vulnerable incumbent in a swing state. And his refusal to accept Medicaid expansions would have left his state’s hospitals on the hook for $2.8 billion when uninsured Floridians show up in emergency rooms, prompting them to lobby Scott to change his mind. And so he has. For an enjoyable sampling of conservative apoplexy, try Philip Klein (“waving the white flag is an accurate description of Scott’s decision”), Mario Loyola (“the most grievous blow since the Supreme Court’s decision upholding Obamacare last year”), and Michael Cannon (“will he sell out Florida’s job creators too?”).
Cannon’s outrage in particular is almost poignant. He has served as a health-care adviser to Scott in Florida, and as a founder of the “Anti-Universal Coverage Club,” lent Scott the closest link, of all the governors, to the conservative movement’s maniacal hatred for providing health insurance to those too sick or poor to obtain it on their own. The ability of governors to turn down Medicaid funding is the last line of defense against Obamacare, and Scott’s betrayal of the cause — choosing the financial health of his own state’s hospitals over the chance to deny medical care to his own state’s poor — lands a blow of both substantive and symbolic power.
We are not about to enter a new era of peace and health-care love. The death struggle between liberals fighting to make health insurance a basic right and conservatives fighting to prevent that is over. What’s replacing it is a more mundane form of trench warfare. The new conservative position will come to revolve around expanding the role and prerogative of private insurance, and the liberal goal will be to strengthen regulation and help the poor and sick.
A glimpse of the new conservative health-care line comes from former Romney adviser Avik Roy and conservative think-tank apparatchik Douglas Holtz-Eakin in a joint-bylined column. In it, they point the way toward the future of the health-care debate. Gone is the millennial struggle to preserve the dying embers of freedom. They actually allow that the central architecture of Obamacare — the establishment of subsidized exchanges where individuals can purchase private insurance — is an “important concession to the private sector.”
Right! It’s a Republican-designed idea! It might have helped if Republicans had noticed this, instead of screaming about socialism, back when Obama was trying to pass the plan.
In any case, Roy and Holtz-Eakin argue that their discovery that Obamacare consists mainly of a free-market health-insurance mechanism offers conservatives a wonderful opportunity. Here their thinking grows extremely confused. The problem with Obamacare , they argue, is that the exchanges are regulated. The “community rating” provision, which prevents insurers from charging higher rates to people more likely to get sick, “will dramatically increase premiums for young people.” They propose to get rid of such regulations and turn the exchanges into a free-market paradise “modeled on the Swiss system.”
As a policy guide, this is utterly daft. Health-care economist Aaron Carroll fisks the op-ed and concludes that they have no idea at all how the Swiss system works. It’s more regulated than Obamacare, not less. Community rating is needed because that’s how you make insurance affordable to sick people — otherwise, insurers will just sign up healthy customers.
But as a political roadmap, Roy and Holtz-Eakin offer what looks like the most plausible way forward for the GOP. The health-insurance industry doesn’t want the government forcing them to sell products to money-losing sick people. Insurers will want to skim the healthiest people from the pool. And conservatives don’t like regulation. That is a perfect match of constituency and ideology.
So the broader struggle will never end. But the conservatives understand that the struggle to preserve “American exceptionalism” in health care — America’s standing as the sole advanced democracy without universal citizen access to medical care — is over.