The Corner

Replace if Repeal: A Response to Some Critics

I published an essay last weekend on Obamacare that made the following points: The ACA is in danger, both from the Supreme Court and the possibility of a Republican in the White House in 2017; a common liberal argument in the face of such danger is that the repeal of Obamacare “equals death;” and “repeal equals death” is not the argument ender that many liberals pretend it to be.

I back up that last point by arguing that public policy makes choices all the time that result in higher rather than lower mortality rates; that in a world of scarce resources such choices are inevitable; and that it is not necessarily immoral to support a policy change even if that policy change will increase the mortality rate. If you disagree in principle, then you should favor a 10 mph speed limit.

Furthermore, liberals aren’t advocating that the goal of health policy should be ensuring “that every person with a treatable disease or injury avoids death,” so they too understand this, and so should stop using the “repeal equals death” argument as if it were an argument ender. I also argue in the essay that conservatives have been guilty in the past of injecting too much talk of death into the health-care debate, and point to Governor Palin’s “death panels” rhetoric as an example.

Having established that, I go on to argue that “if Obamacare perishes — and I hope it does — conservatives should be ready to coalesce around a concrete replacement plan.” I outline such a plan in the essay, explicitly calling for universal coverage as a policy goal, and conceding that “on this point, the president is correct.” I describe what universal coverage should look like, and point out that a Republican plan that would move the health-care system closer to that goal exists in the U.S. Senate. I argue that “repealing Obamacare and replacing it along these lines may result in more people dying — or fewer. That’s a pretty tough forecast to make.”

You can read the whole thing here.

Many liberals have taken issue with the essay. I think my friend and colleague Ramesh Ponnuru is correct that some of them don’t seem to have understood what I was arguing. But there are at least two criticisms worth addressing.

The first criticism is that I would be personally pleased if policy changes resulted in a significant increase in the mortality rate. Some people seem to be responding to the headline — which, following the standard practice in journalism, I didn’t write — described by Jonathan Chait as baldly callous and by Steve Benen as “jarringly callous.”

Ramesh gets it, responding to Mr. Chait:

When Strain writes that it “clearly would not be immoral” to repeal Obamacare, it seems to me in context obvious that he is not saying that repealing Obamacare would be morally okay whatever the replacement. (He’s not saying it would be alright to replace it with a system where it was illegal for poor people to buy health insurance.) He’s saying that the argument that repeal would kill people should not dissuade advocates of repeal, both because that effect is unlikely and because mortality rates aren’t the only criterion for evaluating a health system, although they are of course a very important one.

The second criticism that should be addressed was summarized nicely by Mr. Benen, writing on the Rachel Maddow blog:

There’s no denying the need for trade-offs in any system, and I’d love to compare the trade-offs in the Affordable Care Act to those in the Republican alternative, but at present, the GOP plan does not exist — despite more than five years of meaningless promises from party officials.

This relates to Strain’s thesis, of course, because he seems to believe the destruction of the ACA — leading to “a slightly higher mortality rate” — would be acceptable in part because of a Republican solution that could help take its place. If Strain has seen this elusive, mysterious alternative, here’s hoping he’ll share it with the rest of us.

I have two responses to this second criticism.

First, in the essay I explicitly argue that universal coverage should be a goal of any conservative alternative.

A better discussion, both then and today, is about appropriate social goals and the resources required to meet them. Among the many needed reforms to our health-care system, one should be that we move closer to universal insurance coverage — on this point, the president is correct. But what should universal coverage look like? It requires a nuanced answer.

Even if these liberal writers are correct, it is odd to criticize me for the absence of an alternative, since I am strongly advocating for one.

Second, I think it’s very likely that the congressional GOP would enact some sort of replacement if the Supreme Court strikes down Obamacare (and I think it’s very unlikely that a potential Republican president would repeal it without replacement in 2017). They would very likely take measures to address the needs of those who lost their subsidies as a result of the Court’s action. These liberal writers are not giving the congressional GOP the credit it’s due. From an article in the Hill this week:

Senate Republicans are preparing a legislative plan of action in case the Supreme Court strikes a major blow against ObamaCare and rules subsidies provided to people on the federal exchange are illegal.

GOP senators are confident the justices will rule in their favor, and they want to be ready to act if millions of people lose their subsidies to buy insurance through the healthcare law.

“If the Supreme Court were to say the law says what the law says, we would like to be ready with a response to that that makes practical sense for the 5 or 6 million Americans who would be affected,” said Sen. Lamar Alexander (R-Tenn.), who is heading the effort along with Finance Committee Chairman Orrin Hatch (R-Utah) and Republican Policy Committee Chairman John Barrasso (R-Wyo.).

Senate Budget Committee Chairman Mike Enzi (R-Wyo.) and Sen. Richard Burr (R-N.C.) are also participating.

From Politico, on January 3:

But Barrasso said several groups of lawmakers — members of the Republican Policy Committee and the two Senate committees with jurisdiction over health care — have begun talking about how to build consensus on a replacement plan.

And Brit Hume reported the following on Twitter.

Which brings me back to my original argument: Obamacare should be repealed; it should be replaced with a different plan, a goal of which should be universal coverage against catastrophic expenses so that no one who falls seriously ill or is seriously injured goes without the medical care they need, regardless of ability to pay; and preferring this outcome to the Obamacare status quo is not immoral.

— Michael R. Strain is deputy director of economic policy studies and resident scholar at the American Enterprise Institute. You can follow him on Twitter at


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