Back in May of 2010, just two months after the enactment of the Patient Protection and Affordable Care Act, the director of the Congressional Budget Office casually dismissed the argument that had been used by the law’s champions as the primary justification for its passage. In remarks before the Institute of Medicine, Douglas Elmendorf said that “rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond.” And then he added, almost in passing, “In CBO’s judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.”
In other words, the trusted referees at CBO expected that the law would fail to achieve the most essential task of health-care reform: to bring costs under control.
This pronouncement was not much noticed at the time, because the case for Obamacare had already shifted. Terrified by the political tsunami the law had unleashed, liberals sought to persuade voters not that it would cut costs, but that it would provide benefits they would like, and that repealing it would thus take something from them. Democrats and allied interest groups launched a massive public-relations campaign for that purpose last spring. Television ads telling seniors that they would receive a $250 check in the mail courtesy of the new law were, as the New York Times put it in June, “only an early hint of what is to come throughout the summer and fall, officials say, as other consumer-friendly provisions — a high-risk pool for hard-to-insure people, a Web site comparing coverage plans, tough new restrictions on insurers — take effect.”
The notion that Obamacare would grow more popular as its early provisions took hold was essential to sustaining the morale of vulnerable Democrats in the 2010 election cycle. But of course, it turned out to be false, and most of those vulnerable Democrats lost their jobs. The public’s view of the law has barely budged since its passage, and neither checks in the mail nor any of the other early provisions did much good for Democrats.
Undaunted, Obamacare’s supporters have now moved on to another argument — the most defensive and contorted yet. Having at first proclaimed the law a progressive revolution in American social policy — historic, dramatic, or (in the vice president’s memorable phrase) “a big f***ing deal” — they are now reduced to making their case on the grounds of its supposedly modest reach and its centrism, if not conservatism.
This peculiar justification takes the form of two related sets of claims: that the means employed by Obamacare are actually Republican ideas, and that the ends of conservative health-care reformers can be achieved only by an Obamacare-type system.
Consider, for instance, the argument of Washington Post blogger Ezra Klein, who asserts that Republicans who would transform Medicare into a premium-support system (as Rep. Paul Ryan’s budget would do) should like Obamacare’s insurance exchanges, since they operate on the same principle. “What’s odd about the right’s embrace” of premium support, Klein wrote in March, “is that the plan basically turns Medicare into the Affordable Care Act. It’s the same idea — regulated exchanges offering certified insurance products populated by subsidized buyers.”
#page#Of course, the rule-laden exchanges envisioned by Obamacare would allow significantly less competition than Ryan’s premium-support approach. And more important, if we begin from a fully government-run system like Medicare, a move toward premium support is a move toward the free market, not — as Obamacare would be, since it begins from our private insurance system — a move away from it.
Or consider the case that Simon Lazarus of the National Senior Citizens Law Center made in Slate on May 3. The idea of providing individuals with a tax credit they could use to purchase private health insurance — an idea proposed by John McCain in 2008 and since backed by many Republicans, including Paul Ryan — is actually the same thing as Obamacare’s individual mandate, Lazarus contended. Both create a financial incentive for buying health coverage, so the mandate is no more coercive than the credit. “That means that if the [Affordable Care Act] mandates are unconstitutional, the Ryancare mandates must be as well.” Of course, a law requiring the purchase of a product is hardly the same — in practical or moral terms — as one that provides a benefit for choosing to purchase that product, but Lazarus nonetheless insisted that the logic of the individual mandate is, in essence, the logic of Republican health-care proposals.
When they are not arguing that the law’s means hail from the right, defenders of Obamacare argue that it serves the Right’s ends. For instance, in April, Matthew Yglesias of the Center for American Progress considered the same idea that Lazarus took up — the Republican proposal to turn the tax exclusion for employer-provided health coverage into a tax credit that all Americans could use toward the purchase of private insurance. The proposal has real merit, Yglesias noted, but
to turn this idea into an idea that actually works for people with medical needs you need to do three things. One, you need to prevent firms from turning customers away because of their health status or demographic characteristics. Two, you need some kind of regulatory definition of the minimum benefits that need to be offered in order to qualify as “health insurance” that’s eligible for the tax credit. And three, you need some kind of penalty for failing to enroll yourself in a plan to ensure the existence of a viable risk pool. What you need, in other words, is the Affordable Care Act and its regulate/subsidize/mandate tripod structure.
So the only way to achieve what conservatives want to achieve is through the Democrats’ health-care plan, Yglesias argued. New York Times columnist Paul Krugman and Berkeley economist Brad DeLong echoed his view later in April. “There are alternatives to the left — single-payer, VA-style government provision — but Obamacare is already as conservative as a plan to make health insurance more or less universal can be,” Krugman wrote.
#page#Of course, conservatives have offered alternative means of addressing the problem of insuring people excluded from coverage because of preexisting conditions (a very limited problem, currently affecting perhaps 1 percent of the American population) — most notably, state-run high-risk pools partially funded with federal dollars. The idea that no alternatives to Obamacare exist simply ignores the past several years of Republican health-care proposals.
Beyond the particular weaknesses of these defenses of Obamacare, what stands out about them is their focus on small pieces of the massive law to the exclusion of the whole. This kind of argument-from-the-parts contends that Obamacare is just a series of discrete and modest tweaks of our health-care system, rather than a wholesale transformation, and so any problems with it should be fixed by small changes rather than by repeal. But Obamacare is precisely a wholesale transformation — a massively ambitious, costly, intrusive, inefficient, and clumsy combination of mandates, taxes, subsidies, regulations, and new government programs intended over time to vastly increase the scope of government control over the health sector.
It is not hard to see why defenders of Obamacare no longer want to defend it as a whole. That whole is an incoherent mess and portends disaster for American health care. But opponents of the law should not cede the terms of debate. Many parts of Obamacare are unpopular (the individual mandate to buy coverage, the board of experts that will cut Medicare payments for various treatments, the onerous new burdens on businesses), but it is the structure of the whole that threatens the future of American health care, and it is therefore the whole that must be repealed.
The retreating defenses of Obamacare — from wholesale advocacy, to a case that repealing it would eliminate certain benefits, to arguments for the law as merely an assortment of tweaks — highlight its increasing vulnerability, and with it the vulnerability of its Democratic defenders. In the coming year, the law’s critics need to press their case for repeal and real reform — a case that has not changed, and need not change. That case should be a central plank in the platform of next year’s Republican nominee, since health care is certain to be a prominent and crucial campaign issue. Obamacare’s gross overreach is at the heart of the public’s concern about the current president and congressional Democrats, and its failure to address health-care costs also puts it at the heart of our broader fiscal crisis.
The fact of that crisis means that a case for repealing Obamacare will not suffice. Republicans also need an alternative — a health-care reform of their own that will actually contain costs, and thereby also reduce the number of uninsured Americans and put federal finances on firmer footing.
As the case for Obamacare grows weaker and weaker, the greatest ally its defenders now have is inertia. The law is here, and repealing it will take a great effort. Republicans must be sure their presidential nominee is willing and able to engage in that effort.
– Mr. Levin is the editor of National Affairs and a fellow at the Ethics and Public Policy Center.