That cannot be done in the next four years. But we should nonetheless be laying the groundwork for an eventual replacement of the law: a replacement that may be achieved in one piece of legislation a few years from now, or incrementally in a series of bills.
The core of a replacement would be a change in the tax treatment of health insurance. The tax break for coverage would be flattened and capped so that people would not get a bigger break the more comprehensive their insurance. The break would also be extended to people who do not have access to employer coverage. People would be allowed to purchase health insurance across state lines. Medicaid and Medicare would be converted into subsidies — essentially add-ons to the tax break or credit for coverage — for people to buy private coverage and pay for out-of-pocket health expenses.
Once a robust market for individually purchased insurance has emerged, the problem of people who are locked out of that market because of preexisting conditions should diminish: People will have both the incentive and the ability to buy cheap, renewable catastrophic policies before getting sick. In the interim, though, conservatives should commit to funding well-designed high-risk pools to cover the health-care expenses of sick people who have been failed by the current system. These subsidies will be much cheaper and more likely to work than Obamacare’s solution to the problem, which is a federally imposed redesign of the entire health-care system.
The basic structure of such an approach — which would address the twin problems of access and cost in a way roughly opposite Obamacare’s — has long been discussed by conservative health-care experts. Forms of it have been proposed by George W. Bush, John McCain, Paul Ryan, and even Mitt Romney. More detailed and developed forms have been worked out by a number of conservative policy thinkers in recent years. These ideas are available for Republican politicians, who need to realize that without such an alternative their objections to Obamacare will ring increasingly hollow. Even though they cannot become law for at least four years, such ideas must become Republican orthodoxy if the party is plausibly to call for repeal.
They will also be essential to enabling Republicans to think clearly about incremental steps. While Obama is president, conservatives do not face a choice between offering impossible wholesale transformations and just tinkering with the Democrats’ law. They should look for opportunities, especially amid the coming chaos of implementation, to advance their agenda incrementally and better enable an eventual replacement.
For instance, House Republicans should advance legislation to delay the implementation of Obamacare for a year. It is already behind schedule, and Health and Human Services secretary Kathleen Sebelius has pushed back key deadlines, often without clear legal authority to do so. Why not ratify those delays and put off the new system? Such a move would be something of an embarrassment to the law’s champions, of course. But it would also be a huge relief to them — putting off the greater embarrassment of what looks to be a disastrous implementation process.
It would certainly be helpful to the people actually charged with putting the law into effect, who yearn for more time to try to make that implementation less disastrous. And it would be helpful to the law’s opponents too, since we believe that the disaster is a function of the law’s very design (and so not ultimately avertable by delay) and that the more time we have to help people see the flaws in that design, and to advance superior alternatives, the more likely we are to replace the law before it has become entrenched.
Republicans could also push to repeal IPAB: to strike a blow against the centrally managed price-control model of health-care reform at the heart of Obamacare and force a very difficult vote upon the Democrats. They could move to strip out some key taxes, such as the medical-device tax, or to repeal the individual-mandate tax. Or they could offer states far greater latitude to control their Medicaid dollars, whether they have opted for Obamacare’s Medicaid expansion or not, in return for a cap on federal Medicaid spending. Each of these moves would make both a point and a difference.
A continued insistence on repeal may seem quixotic; certainly that’s what supporters of Obamacare will say. But the prospects for repeal — or for reforms amounting to repeal – depend on whether conservatives’ warnings about the effects of Obamacare are correct. Higher premiums and larger budget costs, should they materialize, are not going to make the law turn popular for the first time.
Some conservative pessimists warn that Obamacare’s failure will result in a single-payer solution. We do not share this fear. In 2009–10, liberals had more power in Washington, D.C., than they had had at any point since 1966. Still they could not achieve a single-payer system, or even a “public option” that could metastasize into one. Liberals now own the health-care system. If it fails to work as they have projected, they will be discredited rather than empowered. The public will not be eager to turn itself over to them for more experimentation. It will be more likely to turn to those who warned all along that Obamacare would not work.
But that is precisely why it is crucial for conservatives to rally around both a serious, broad vision of what a conservative health-care reform would look like and a set of incremental steps that might begin to move the country in its direction even now. That task begins with accepting the possibility that we have not already lost.