The Republican Agenda on Health Care
Those interested in the future of health care reform should definitely check out Andrew Sprung's "what if?" piece on what Republicans would actually do if they had the chance after 2016. Sprung talks to three economists to get a sense of it. It's an outstanding article.
The first thing to note is that repeal is, in fact, dead. There's simply no way to go back to the status quo ante. And in fact, hardly anyone would want to, including conservative policy wonks.
What I took away from the piece, however, was a bit different than that. It was that Republicans may be constrained by their own rhetoric into framing whatever they would want to do to improve (from their point of view) the new system as "repeal" and replace, even if the replace part of it basically just revives the things they are repealing.
In other words ... no one is going to simply shut down the exchanges (at least in the states where they are working, which will likely be the overwhelming majority of the states). No one is going to push young people off of their parents' plans (or, to be more precise, allow insurance companies to do so). The Affordable Care Act was a large and complex law; there are all sorts of provisions in there that people now rely on and plan around, and for the most part no one is going to want to cause the disruptions that pure repeal would produce.
And yet there are quite a few conservative reforms which could certainly build on the structure that's now in place. Some of those reforms, as Sprung details, many liberals and liberal policy experts would be perfectly happy with. Some others wouldn't actually work well in practice, regardless of their rhetorical repeal. But the point is that a serious Republican Party would have an active health care agenda. It just won't (really) involve eliminating the ACA, just as the ACA itself didn't eliminate lots and lots of previous reforms and policies.
However, activists within the Republican Party are simply not going to accept "building on Obamacare" as a platform, at least not any time soon. What that means is that policy makers are going to have to, essentially, disguise "building on Obamacare" as "repeal and replace." Which has two problems. One is that it may add considerable otherwise unnecessary policy complexity. The other is that it's going to be vulnerable to charges that it doesn't fully repeal Obamacare -- because it won't! Remember, for example, the revolt against Eric Cantor's bill to expand high-risk pools because they were tainted by their inclusion in the ACA. The problem is that President Barack Obama basically told the truth when he said that the Democratic bill included many Republican ideas, which means that there are relatively few "pure" conservative ideas available that have no association at all with the dreaded Kenyan socialist.
Now, it's certainly possible that if Republicans really do capture the White House, the Senate and the House in 2016 that they'll forget all about that when they prepare health care legislation, and actually just pass a straightforward bill. They can always "repeal" the exchanges and replace them with Ronald Reagan Free Enterprise Private Insurance Access Points, and then move on to the sorts of things that conservative reformers want to add to Obamacare. And with a Republican in the White House, it's very possible that activists and the conservative press will go along.
It's also possible that the risks of further health care reform will be relatively low-priority for most Republicans; they may be perfectly happy to have a Democratic filibuster kill something, and then move on to tax cuts or some other lower-risk, higher priority policy. In fact, that would be my bet. Health policy is hard, and I'm not convinced that Republicans are anywhere close to ready to tackle it, or that they have all that much of an electoral incentive to do so.
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