The Corner

Welcome to the Era of GOP-amacare.

From the Tuesday edition of the Morning Jolt:

Welcome to the Era of GOP-amacare.

Phil Klein of the Washington Examiner looks at the current Republican Obamacare replacement plan and concludes that the GOP isn’t going to change nearly as much as conservative free-market health-care-policy wonks hoped:

Supporters of the bill could argue that it does make changes to Obamacare — repealing taxes, reducing spending, and scaling back some mandates and regulations. There are even a few areas in which one could argue the bill moves health policy in a more conservative direction relative to the pre-Obamacare status quo. It provides for expanded health savings accounts and, though it would spend more money than otherwise would have been the case before Obamacare, it would overhaul Medicaid into a program in which states are given a per capita grant and provided the flexibility to run their own programs.

But at the same time, the GOP bill preserves much of the regulatory structure of Obamacare; leaves the bias in favor of employer healthcare largely intact; replaces Obamacare’s subsidies with a different subsidy scheme; and still supports higher spending for Medicaid relative to what was the case before Obamacare.

Ultimately, it doesn’t do much to foster the development of a free market system. Under GOPcare, individuals would not be able to take insurance with them from job to job, because tax credits would not be available to people who have an offer of job-based insurance. They would not be able to purchase whatever plan they want, because the federal government will still be dictating what has to be in insurance policies, making insurance more expensive then it needs to be. If this bill passes, everybody would have to get their insurance either through government, their employer via tax subsidy, or be left to purchase government-designed health policies using federal subsidies.

For a long time, policy wonks on the right have argued we need a system of health insurance where your plan follows you from job to job instead of being offered by, and primarily paid for, by your employer. It would be a better idea, but it’s extremely difficult to implement, particularly if you want your employer to cover the same share of the cost from job to job. Currently, most plans aren’t offered nationwide.

Among the health plans 156 million of us get from our jobs, only a few insurers offer national networks of participating doctors and hospitals. And most of the plans available to people who buy their own insurance through the individual or small group market are local and limited by specific geographic areas. Policyholders who move away generally must change carriers. And insurers sometimes pull out of markets, meaning stranded consumers would also have to pick new plans.

Employer-based health insurance works with you kicking in a certain percentage of the costs (usually a small one, even with the deductibles, premiums, and co-pays) and your employer kicking in the other percentage. A 2016 study found the average percent of health insurance paid by employers is 83 percent for single coverage and 72 percent for family coverage. How do you design a plan where the party that’s covering 72 percent of the cost can be removed — the employee is fired, laid off, or quits — and the employee can maintain the coverage until they find a new employer?

Health Savings Accounts? They’re a terrific idea. But a lot of people don’t have good impulse control and don’t save money the way they should. They don’t save for retirement, they don’t save for their children’s college educations, and they don’t save for unexpected expenses. A certain percentage of the public simply won’t save for health expenses.

For the past few weeks, I’ve been joking, “Republicans are set to replace Obamacare’s system of subsidies, where the government gives you money to help pay for health insurance, with a system of refundable tax credits, where instead, the government will give you money to help pay for health insurance.” (I wonder how many readers will think there’s a typo in there somewhere.) Is this a surrender? Or is this a concession to the realities of the issue? I’m sure there are a lot of free-market purists who would love to repeal Obamacare’s expansion of Medicaid and yank away coverage from about 10.7 million people, and leave it to them to find affordable replacement coverage. For obvious reasons, Republicans in office are not eager to embrace this plan.

The editors of NR have more or less made their peace with the idea of replacing subsidies with tax credits:

. . . we will stipulate that in an ideal world we would not be subsidizing health insurance as much as we do and perhaps not at all. But there’s no compelling reason to maintain subsidies for a much larger number of people while cutting off a small number cold turkey.

Political considerations buttress the case for providing tax credits to this fraction of Americans. For seven years, Republicans have been saying that they would “repeal and replace” Obamacare when they got the chance. They didn’t say that they would only repeal it, and they did not include the word “replace” only because conservatives have health-policy ideas of our own that we would like to see implemented. They included it to reassure people who had gotten insurance through Obamacare that they would not be left without coverage in a post-Obamacare world. Republicans cannot keep that promise, which seems to have been important to a significant number of voters who backed them, without a tax credit.

Tax credits would promote a stronger individual insurance market, a more level playing field for different types of insurance, and Republican political health. Those interests ought to be considered sufficiently strong to overwhelm our friends’ objections.

Klein concludes, “Liberals, in other words, have won the central philosophical argument, and Republicans are reduced to fighting over the mechanics.” He is right, but we shouldn’t be surprised, because the conservative argument is thoroughly unappealing. The liberal argument is “somebody else” should pay for your health care (meaning everyone through taxation). The conservative argument is that you should pay for your health care.


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