Repeal, Replace, Reform, Rewind

by Ramesh Ponnuru

Avik Roy has been arguing for some time that Republicans should push for reform of Obamacare, rather than its repeal and replacement. And for almost as long as he has been making that case, I have been saying that the “reform” he seeks would amount to replacing Obamacare, and that the rhetoric of “repeal and replace” is superior to that of “reform” of Obamacare. I again made those points in a post two days ago. Roy responded last night.

The difference, he suggests, is more than rhetorical. Here’s Roy: “Ramesh argues that migrating the Medicaid population onto a reformed, deregulated set of insurance exchanges would be more disruptive than block-granting Medicaid (the traditional repeal-and-replace plank). I don’t agree.” I made no such argument in that post, nor have I made it anywhere else, and I have no idea where Roy is getting this idea. As it happens, neither of the ideas Roy is contrasting would be my first choice for fixing Medicaid. I’d prefer to convert most of it into a kind of premium support that beneficiaries could use to buy insurance on the individual market–which would solve the problem of “churn” that concerns Roy. To return to my main point, though, any one of these three ideas could be described as a “reform” of Obamacare or as a “replacement” for it. Roy’s proposal — changing the exchanges a lot and then having them swallow Medicaid — obviously entails rewriting the law substantially. It’s not some minor fix.

Roy argues, as well, that reform is more politically attractive than repeal and replacement. At least, that’s what I think he’s getting at with all the polls he cites. I wouldn’t be surprised if a well-constructed poll found that, as he suggests, “reform” polls better. “Reform” probably sounds gentler than “repeal and replace.” I am surprised that Roy was unable to find such a poll. Instead he cites four polls. He admits that one of them used skewed terminology. Actually all four did, if we go by Roy’s description of them. NPR and Bloomberg omit any mention of replacement; Kaiser associates repeal-and-replace with “Republicans” while omitting any partisan identifier for its other three options. (I wonder how well Roy’s suggestion would test if it were worded as a “Republican-sponsored reform of the health-care law” while other options ignored parties.) As I said, though, fairly worded polling might find an advantage for “reform,” and that would certainly be something for Republicans to keep in mind when deciding how to talk about health policy. I don’t think it clinches the political case, though, because a campaign to move health-care policy in the right direction needs not only to sound like a good idea to folks in the middle but also to motivate people on the right to work for it. “Repeal and replace,” even assuming that it sounds too dramatic for many people, still seems to me the politically wiser way to go.

And I also still think it’s a more accurate description of what Roy is trying to do, and what conservatives should be trying to do.