AP Photo/Carolyn Kaster
President Barack Obama pauses while speaking at a campaign event, Saturday, Aug. 18, 2012, in Windham, N.H., at Windham High School.
You can just feel conservatives' glee as they await the "implosion" of Obamacare.
Whether it's technical problems with the health care exchange websites or low participation in the insurance pools, they see big problems on the horizon that will doom Obamacare, and they are psyched.
Tom Miller has a "reality check" for conservatives in the current issue of National Affairs: While Obamacare is going to cause big problems, it's not going to explode in a fireball of health care disaster. Conservatives can only defeat it with a plausible plan to replace it, says the health policy scholar from the conservative American Enterprise Institute.
Unintentionally, Miller's "reality check" explains why conservatives can't come up with an approach to health care other than waiting for Obamacare to fail.
Though Miller spends 6,000 words laying out his health policy vision, he never explicitly notes two facts about his approach: It would cost a lot of taxpayer money to implement, and it wouldn't achieve universal health coverage. The former makes the approach a nonstarter for so many conservatives that no Republican Congress would ever implement it. The latter makes it unsaleable to the broader electorate.
For example, here's what Miller says about high-risk pools, or government entities that subsidize coverage for people with costly chronic medical conditions:
We should be more generous in targeting persistent, condition-based problems and vulnerabilities. Subsidizing access to health-care choices in a competitive marketplace (through high-risk pools, for instance) is preferable to directly providing services through government channels, although markets alone do not and cannot meet every medical need.
High risk pools already exist in most states but they don't work very well because subsidizing care for the chronically sick is expensive and states don't tend to fund the pools very well. Miller and Jim Capretta wrote another article for National Affairs in 2010 with a solution to that problem: federally funding high-risk pools, which they estimated would cost $15 to $20 billion a year.
And some Republicans are down with the federally-funded high risk pool approach. In April, in an effort to show that Republicans have an alternative vision for health care reform, House Majority Leader Eric Cantor (R-Va.) brought forward a plan to divert $3.7 billion over four years from Obamacare into high risk pool subsidies.
That's about 5% of the amount the Capretta-Miller plan would cost, but it would be a start. Yet, Cantor had to pull the bill from the floor because Republicans were unwilling to spend even that much money on the high risk pool approach.
Rep. Raul Labrador (R-Idaho) told Talking Points Memo that "subsidizing health care is not what Republicans should be about."
In 2010, when Rep. Paul Ryan (R-Wisc.) and Sen. Tom Coburn (R-Okla.) advanced their alternative to Obamacare, one argument they made in favor of their plan was that it did not spend any federal money on high-risk pools, unlike a plan previously advanced by Sen. John McCain (R-Ariz.) which they complained would have " [cost] the taxpayers hundreds of billions of dollars over a projected budget window."
The problem for Miller is not that conservatives are too busy opposing Obamacare to sign on to his approach to fixing health care. It's that conservatives oppose his approach to fixing health care.
At the same time Miller asks for money for the sick that Republicans won't give him, he's also calling for rolling back coverage in a way the broader public won't appreciate. Most plans for health reform focus on reducing uninsurance and improving access to coverage. Miller actually calls for shrinking Medicaid coverage for healthy adults—but he makes the call in a convoluted way that you might miss if you're not paying attention. Emphasis added:
Income-based financial support from taxpayers to address health-care vulnerabilities should distinguish better between short-term emergency assistance and longer-term arrangements for those suffering from chronic or permanent conditions. Reformers need to have in mind a socially conscious "floor" for the former — both in dollar amounts and eligibility duration for catastrophic coverage — while avoiding the danger of setting a ceiling on personal responsibility, economic initiative, and social mobility. Short-term assistance can provide stability and opportunity to rebound from health-related misfortune, but it should not dull the incentives to regain more self-sufficiency after the crisis is over.
In other words: Reduce Medicaid for healthy adults to "catastrophic" coverage covering major health events instead of the broad coverage it is today, and impose a time limit on its use, so that healthy people who end up long-term unemployed with almost no income also end up uninsured.
If you explained Miller's plan in clear language to the public ("we're going to spend a bunch of money and we're going to take health insurance away from people who have it now") it wouldn't go very far. If this is the available policy alternative, it's pretty easy to understand why Republicans have ditched it for a facile "defund Obamacare" message.
Other parts of the article reflect how shallow conservative thinking on health policy tends to be, including Miller's. In a section on delivery reforms, he bemoans conservatives' failure to advance alternatives to Obamacare's "science-fair of medical-delivery experiments and untested vaporware," such as bundled payments and accountable care organizations. But then three of the four principles he lays out for such alternatives are exactly the same ones underlying the Obamacare approach:
First, they must redesign payments so they reward results rather than try to micromanage processes as they do now. Second, they should better measure what matters to patients and other private payers. Third, they need to remember that favoring competition is not the same as (and indeed must be at times the opposite of) protecting incumbent business interests.
This is what liberal health policy wonks have been working on for the last five years while conservatives have invested their energy in trying to undermine and tear down Obamacare.
Miller is right that conservatives are being undone by their unseriousness on health policy. But the patient can only get better if he wants to.
The failure of conservative politicians and think tanks to advance serious alternatives on health policy reflects their complete lack of interest in fixing health policy: They don't want to spend money, they don't want to change Medicare in ways that affect elderly Republican base voters, they don't want to cut the incomes of Republican-voting doctors, and they don't want to change the (often overly expensive) health coverage situations of the overwhelmingly insured Republican electorate.
They do want to stop Democrats from having legislative accomplishments. Sometimes, conservative health care "plans" are useful as a concern trolling exercise to interfere with Democratic legislating on health care. But Republicans are not about to let their own side's plans get anywhere near the implementation stage, lest they do any of the things I listed in the above paragraph.
I understand Miller's frustration. It's tough to sell a product that nobody wants to buy. But he should try harder to understand why he's not making the sale.
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