the national interest

Pretend GOP Urged to Adopt Imaginary Health Plan

A tea-party supporter protest outside the US Supreme Court on the third day of oral arguements over the constitutionality of the Patient Protection and Affordable Care Act on March 28, 2012 in Washington, DC. The 26 states challenging the law argue that the Affordable Care Act must be completely repealed if the requirement that all Americans buy health insurance -- known as the
You, in the clown makeup – you seem to have some innovative proposals for state level high risk insurance pools you want to propose. Photo: MLADEN ANTONOV/AFP

Yuval Levin, the influential Republican policy adviser, and Ramesh Ponnuru have a (paywalled) cover story in National Review urging Republicans to stand fast in their fanatical determination to repeal Obamacare. As a piece of policy analysis, it is not remotely persuasive. What is interesting about it is the delicate balance it strikes as the authors try to carefully coax the partisan rage of the party faithful toward their desired policy ends while avoiding any engagement with the cruelty and indifference of the actual Republican agenda.

Levin and Ponnuru mainly reprise familiar conservative criticisms of Obamacare. This passage jumps out as especially telling:

The law also vastly expands Medicaid, which is a crummy form of insurance: Researchers who compare the program’s beneficiaries with people who have no insurance at all often have a hard time finding much of a difference in health.

There’s a common talking point on the right that Medicaid doesn’t make its recipients any better off. How, you might wonder, can it be that paying the cost of being treated and given medicine for people who can’t afford it won’t make them even slightly healthier? The answer, as Jonathan Cohn and Austin Frakt have patiently explained, is that it can’t be. Measuring the impact of any medical intervention is, for various reasons, extremely hard. The handful of studies that haven’t found Medicaid recipients getting improved health outcomes suffer from the flaw of failing to control for who is going on Medicaid to begin with. It’s not random: people who enroll on Medicaid tend to have serious health problems to begin with. The best study of this occurred in Oregon, where you had a rare random experiment: The state held a lottery for a limited number of spaces in its Medicaid program, and lo and behold, people who got it turned out healthier.

Levin and Ponnuru are honest enough to cage their version of the Medicaid-doesn’t-help claim in weasel words — “often have a hard time finding much of a difference in health” — that, if you think about them carefully, strip it of most of its punch.

Yes, Obamacare covers a lot of people by putting them on Medicaid. And yes, Medicaid is crummy. Why is it crummy? Because it’s super cheap — it pays doctors much less than Medicare does, and Medicare of course pays much less than private insurance does. They don’t mention the Republican budget plan (cutting Medicaid by a third) which would make the program much crummier.

Likewise, Ponnuru and Levin lambaste Obamacare for its failed gesture of helping really sick people before the main plan goes into effect by setting up special state-level insurance pools for people with really expensive conditions:

Obamacare created high-risk pools as a temporary bridge to the full implementation of the law’s provisions for people with preexisting conditions, but these attracted far fewer people than anticipated and yet ran out of money far sooner than projected.

Fair enough. High-risk pools are pretty lousy, even as a stopgap solution. But when we get to the section of the article where they have to come up with their own proposal to insure really sick people, I see this:

conservatives should commit to funding well-designed high-risk pools to cover the health-care expenses of sick people who have been failed by the current system.

Wait — they’re proposing the same thing they lambasted Obama for enacting eight paragraphs earlier! What’s the difference? Okay, their high-risk pools would be “well-designed.” Exactly what special design elements they would have for a system that pays insurance companies to cover people with incredibly expensive health-care needs, they don’t say. “Well-designed” is just a magic wand that allows them to counterpose an imaginary alternative against an actually existing one. Using the power of fantasy, they have transformed the Republican Party’s actual plan to impose massive financial risk and deprivation upon the poor and sick into an earnest search for a more technocratically pure alternative.

In fairness to Levin and Ponnuru, they do urge Republicans to pair their repeal proposals with some kind of alternative. Republicans, they plead, “need to realize that without such an alternative their objections to Obamacare will ring increasingly hollow. Even though they cannot become law for at least four years, such ideas must become Republican orthodoxy if the party is plausibly to call for repeal.”

This passage, while written in the proper spirit, takes the frequent approach of casting the desire to alter the party’s approach as a future conditional –— will ring hollow, if the party calls for repeal. This has already happened. The GOP has held countless votes to repeal Obamacare and replace it with nothing. They have voted several times for a budget that does the same (and then cuts health-care subsidies for the poor and sick even further). This is the plan. Republicans have had so many chances to replace Obamacare with something else — during the health-care debate, when Paul Ryan was crafting his master 40-year blueprint, during the presidential campaign.

Republicans haven’t done so for pretty clear reasons. These alternative proposals are much less technocratically simple than they pretend. (You can’t just throw terms like “well-designed” at the Congressional Budget Office.) They cost money Republicans don’t want to spend. They upset voters and interest groups Republicans don’t want to upset. Instead they’ve made a decision that they’d rather keep taxes low than spend money to cover the uninsured.

The most important step in getting Republicans to actually commit to an alternative is changing that. Changing it means disagreeing with the actual Republican plan, not treating it as a hypothetical future choice. Otherwise, all Levin and Ponnuru are doing is providing intellectual cover to the party’s drive to make 50 million Americans fend for themselves.

Pretend GOP Urged to Adopt Imaginary Health Plan