Avik Roy continues his lonely campaign to get conservatives to drop the idea of “repealing and replacing” Obamacare and instead to embrace reforming it. The distinction has always seemed to me to be one of rhetoric rather than substance, the reforms to Obamacare that Roy seeks being so far-reaching as to amount to a replacement of it. And I favor “repeal and replace” over “reform” as a slogan for two reasons. First, it seems to me to do a better job of capturing the fundamental difference between the philosophy underlying the system conservatives should want and the one that liberals do; second, it seems to me politically superior because the rewards of galvanizing opponents of the law exceed those of mollifying supporters and neutrals. (That second judgment is, of course, a contingent one.)
Roy’s latest post does not alter any of these views of mine, although it makes it clearer that Roy himself sees a substantive difference. Replacement, he thinks, would necessarily entail more disruption than reform for people in what he calls “Obamacare-sponsored health-care coverage.” I don’t see how this could be true. Voucherizing much of Medicaid is equally disruptive whether you package it as “replacement” or “reform,” and measures to make it less disruptive are compatible with a phased-in “replacement” as well as a phased-in “reform.”
It is worth noting, as well, that Roy’s conclusion that Obamacare is here to stay hides an awful lot of ambiguity. Obamacare is a moving target. That’s not just because, although it is partly because, the administration has shown itself willing to rewrite the law as it goes along. It’s also because the law itself is scheduled to go through major changes. Consider the changes that the statute itself sets in motion for the presidential term just after this one. The Cadillac tax goes into effect; several of the insurer protections, such as the risk corridors, expire; the Medicare cuts start biting hard; the state portion of payments for the Medicaid expansion increases. Taken together, I think these changes mean that a law that is already unpopular starts to take on an even less attractive cast. Obamacare is going to keep changing, and in ways that may increase pressure for more change still.