How to Replace Obamacare: Focus on the Real Problems
At the Washington Post, Ezra Klein wrote a lengthy piece responding to a list I assembled last year of the outline of a Republican replacement for Obamacare. Here's his essential argument:
This isn’t a plan to “replace Obamacare.” It’s a plan to do the opposite of replacing Obamacare. It’s as if I said I had a plan to fix the house by replacing the leaky roof, and you said you had a plan to fix the house by getting rid of the roof.
The confusion here is the term “replace Obamacare.” Obamacare is, at its heart, a policy to make sure most every legal resident of the United States has access to comprehensive, affordable health care. In order to achieve that goal, it helps poorer Americans pay for insurance and regulates the products offered by insurers to make sure they’re worth paying for.
The eight-point program Domenech lays out is not an alternative approach to achieving the same goal. It’s actually an effort to achieve an almost perfectly opposite goal. Rather than make comprehensive insurance more accessible through government subsidies and regulation, it makes insurance stingier and rarer by removing government subsidies and regulation.
The essential premise of Ezra’s piece is that Republicans have no plan for replacing Obamacare because none of the Republican plans does the same things Obamacare does, at least on paper. In other words, to qualify as an Obamacare replacement, your plan has to accomplish pretty much the same thing, with pretty much the same methods. This strikes me as a bit of a game, especially given the conflation of ends and means: if I replace my Ford with a Honda, do I still have a car? Or my desktop with my laptop – do I have a computer? Or sugar with Splenda… you get the idea. But then Ezra goes on to spend 2400+ words criticizing Republican plans. This itself is a welcome acknowledgement that these Republican plans must in fact exist, which was the whole point of my original post. Ezra’s real contention is not "You have no plan", but "Your plan is all wrong." Good! Now, four years later, we can have a debate.
The eight points that I noted as principles shared by the overwhelming majority of Republicans approach health care from a different perspective than Ezra and the Democrats. The accusation on Ezra’s part is that Republicans think we have too much insurance. He’s basically right – but there is a difference between saying “we have too much insurance” and saying “we have too many people insured”. It’s important to be careful here, because we’re judging how a Republican plan would work against how Obamacare’s supporters claim it would work, or ought to work. Democrats see getting insured as an end; but for Republicans, more healthy people is the end.
What most of the conservative health policy experts on the Right want is greater access to quality, affordable care. They understand health insurance does not guarantee quality health care any more than car insurance guarantees you a mechanic who fixes what's actually wrong with your car without overcharging you. They want people getting insured because insurance is more affordable, competing in a marketplace to provide people with what they want – and thus Republicans are focused on cost, while Democrats are focused on coverage.
It's also worth your time to read Yuval Levin respond to similar critiques from Matthew Yglesias and others.