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After Obamacare: What Do Conservatives And Republicans Want on Health Care?

Democrats trying to defend their flailing healthcare bills have tried, repeatedly, a two-pronged attack on the mostly united Republican opposition to the various plans floated by the Senate and House Democrats and the Obama White House. One is to suggest that Republicans are criticizing the proposed Democratic solutions without having any of their own – implying that there really is no other choice but to pass a Democratic bill and that Republican opposition is irresponsible. The other and related contention is to argue that Republicans have a responsibility to cooperate in bipartisan fashion on the bills currently under consideration, rather than seek those bills’ defeat.

These arguments are useful as political spin, but they are wrong. Moreover, they ignore the fact that the GOP has opposed the healthcare bills with much the same strategy employed by the Democrats against George W. Bush’s effort to reform Social Security – which almost certainly resulted in the destruction of any chance in the foreseeable future to fix Social Security’s fiscal problems or even prevent them from getting worse – as well as by forces both Right and Left against the Bush-McCain-Kennedy comprehensive immigration bill.

For the uninitiated, here’s a sampling of what conservatives and Republicans do think about health care. I can’t speak for everybody, but I think I can explain in general what the majority of the Right thinks and wants on this isue, and why it precludes most if not all elected Republicans from supporting any comprehensive healthcare bill built along the lines of those floated over the past year:

1. The System Is Not That Bad: The fundamental disconnect starts at the beginning: by and large, most people on the Right think the United States has a great healthcare system, the best in the world. Pretty much nobody thinks the system is perfect: there are lots of skewed financial incentives, lawsuits are too expensive and prevalent, costs are excessive in some parts of the system, and there are, in fact, too many people who don’t get care they need. The system is messy in much the same way that democracy and free markets are messy, and similarly in need of constant tweaking. But the general feeling among conservatives and Republicans is that while you might make fundamental changes in the structure of the system if you were starting it from scratch, when you’re dealing with the system as it is, the best thing to do is work around the margins rather than launch a massive federal takeover of the whole shebang that rewrites every aspect of the system from Washington with no possible way to anticipate how all those changes will play out.

That very premise is the basis of the deep divisions over this issue, and helps explain why the further the process has advanced, the more public opinion has favored the opposition, despite the generalized initial public sentiment that “reforms” should be implemented. If the voters are leery of drastic, comprehensive systemic “reform” now that they have had time to see what it looks like, they will naturally prefer doing nothing at all. Maybe the opportunity won’t come this way again soon to do a fundamental overhaul of the system, but there’s always a next year to do smaller, more incremental bills that work around the margins. That’s precisely why the GOP has suffered no political damage for not having its own comprehensive plan – GOP solutions like permitting insurance to be sold across state lines are piecemeal and can be enacted as such without having to get all the moving parts into the same bill.

This is the diametric opposite of President Obama’s position. As the President put it in last week’s State of the Union Address:

There’s a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. (Applause.) Let me know. Let me know. (Applause.) I’m eager to see it.

There you have it – he’s only willing to consider an alternative proposal if, in his view, it reduces premiums and reduces the deficit and covers all the uninsured and “strengthens” Medicare, and clamps down on “abuses” by insurance companies – even a proposal guaranteed to do any one of those things is unacceptable.

That’s a recipe for giving Republicans no choice but to simply say “no.” But it doesn’t mean the GOP, if it took control of Congress, would be unwilling or unable to present the Obama White House with bills that could address particular problems with the system.

2. What Matters Is Health Care, Not Health Insurance: The core concept behind comprehensive reform is that the federal government has a responsibility to eliminate with one fell swoop the estimate tens of millions of people (nobody knows the real number) who lack insurance. This is one reason why the Democratic plans all include a mandate that compels citizens to purchase insurance, and why they also include a battery of other interlocking provisions designed to control the allocation of risks, the imposition of costs, and the terms on which insurance can be offered or coverage denied. Despite all of that, it remains questionable whether the uninsured would truly be eliminated under any bill on the table – to pick two examples, illegal aliens may be hesitant to claim coverage (and could be barred from coverage, depdning how one reads the bills), and if the less onerous penalties for refusing to buy insurance are selected (the Senate bill won’t criminalize refusing to participate in the mandate; the House would), some young, healthy people will just pay the fine and opt out of the system.

Is it worth disrupting the health insurance arrangements of the insured majority to extend coverage to the uninsured minority, and perhaps not even all of the uninsured minority? To answer that, you need to remember that what matters isn’t insurance, it’s care – the sole purpose of health insurance is to secure access to health care.

And people without insurance in this country still get health care, often from sources like clinics and emergency rooms. Not all the care they may want or in some cases need, nor the best or most cost-effective care. And of course, not everyone with insurance receives perfect care either. Many of the distinctions between the insured and the uninsured are differences of degree. Moreover, many of those who lack private sector insurance are covered under Medicaid or Medicare.

Conservatives don’t argue that this is an optimal situation – but we do argue that in light of these realities, it’s entirely acceptable to focus on solutions that improve access to both insurance and care, rather than guaranteeing insurance. If you can reduce genuinely unnecessary barriers to competition and low-cost insurance, if you can provide better ways for people to shield assets from taxation to spend on healthcare – these are goals that can reduce the number of people who lack insurance, without necessarily having to come up with a single magic bullet that claims to eliminate the lack of insurance overnight.

3. Let A Thousand Flowers Bloom: A fundamental objection to Obamacare in its various forms is that by enacting a vast new federal regulatory and entitlement structure, it freezes the entire industry in amber in ways that will choke off the possibility for future revisions. The political trauma of the efforts to enact this legialstion only underscores the extent to which politicians will be unwilling to revisit comprehensive changes in the future. If it passes and doesn’t work out perfectly – and how many government programs do? – neither the states, nor the private sector, nor in all likelihood future Congresses will be able to fix it. Like Medicare, it will simply run on autopilot forever more.

This was one of the objections Scott Brown raised in the Massachusetts Senate race: Massachusetts has its own statewide system of “Romneycare,” which had many similarities to the federal program. But the Massachusetts Legislature today remains free to alter or repeal or defund Romneycare, much the way that Tennessee’s Democratic Governor Phil Bredesen has done with TennCare, the system originally modeled after Hillary Clinton’s health care plan, when it grew too expensive for his state.

The states are, in Brandeis’ term, the laboratories of democracy for at least two reasons. One, multiple states can try differing approaches, and learn from each others’ experiences – whereas once the federal government acts, innovation is at an end. Two, states do not have the federal government’s budgetary processes – many have balanced budget amendments or other constraints on deficit spending, they have to compete with rival states to keep taxes reasonable, some have line-item vetos, zero-based budgeting or other tools Washington lacks for revisiting budgetary decisions annually, and the partisan/ideological temperature is lower in many statehouses. When forced to make genuine choices among competing budgetary priorities, states can’t just choose “all of the above.”

The diversity of state and private-sector approaches is also evident in the debate over rationing of care and whether this will lead to government “death panels.” It is true that rationing in one sense or another – that is, decisions to forego some care on cost/benefit grounds – will occur in any remotely fiscally responsible healthcare system. It is arguable, even, that not enough rationing is done today. Ideally, rationing should be done by the consumer, as happens in any field where consumers, rather than insurance intermediaries, make purchasing decisions; as Wisconsin Congressman Paul Ryan, the GOP’s go-to guy on health care these days, explains:

Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?

… what I’m saying is that rather than having government ration care to manage decline, let’s take those market signals that work in every sector of the economy to reduce cost and improve competition. I got Lasik in 2000. That’s a cash surgery. It cost me $2,000 an eye. Since then, it’s been revolutionized three times and now costs $800 an eye. This sector isn’t immune from free-market principles.

What’s particularly menacing about putting rationing power in the monpolistic hands of the vast, impersonal and bureaucratic federal government is, again, that it eliminates the possibility of competition or outside supervision putting any counterweight on the desire to control costs. It’s possible, of course, that the federal government will respond to concerns about rationing by being profligate, but that presents the opposite problem of hemhorraging money. Either way, the system becomes much less fluid when a single actor with the coercive power of the state behind it is calling the shots.

Even where the GOP has more ambitious proposals for reform, they are not based on top-down diktats from Washington; Ryan argues for a broader, less incremental approach than many in the party, but his proposals would operate by gradual, voluntary reform of existing structures through the market, rather than an avalanche of new regulation driven from a single office in the capital:

We set up state-based exchanges. You don’t have to participate in the exchange if you don’t want to. You don’t have to sell it in the exchange if you don’t want to. I don’t want a closed system that will gravitate towards more government control. I want it to be decentralized that has regulatory competition and market competition. You can be in or out of the exchange, which keeps everybody honest.

Note the emphasis on avoiding individual or employer mandates, thus avoiding the most freedom-encroaching aspects of Obamacare while also eliding the major Constitutional objections to compelling people to buy a private company’s products, as well as the essentially corrupt nature of tethering individuals to a government-compelled relationship with large insurers.

4. This Is Still America: The final really core disagreement is that many Republicans and nearly all conservatives object on principle to making health care a fundamental entitlement guaranteed by the national government. Experience the world over shows that health care is one of the most critical tipping points in altering the relationship between the citizen and the government in cradle-to-grave social-welfare states on the European model (when people call Obama a “socialist,” this – along with de facto direct government control of major industries – is what they are thinking of). Having health care systems run at the state level is bad enough, but having them uniformly dependent upon Washington for funding and regulatory favor simply takes too many of the most important things in life and puts them in a single pair of hands. That’s not the American Way, and if that sets us apart from other nations, it should.

When all is said and done, when 2010 has – as it seems increasingly likely – come and gone without the passage of a sweeping comprehensive federalization of health care, Republicans in due course will offer, and will need to offer, constructive solutions of their own that can marshal support across the GOP and, hopefully, in some cases across party lines. But what will be clear is that those solutions will not be just mirror images of the Democrats’ vision. They will instead reflect these core distinctions: incrementalism over one-bill-to-rule-them-all; a focus on increasing access and decreasing cost rather than making sweeping guarantees; avoidance of coercive government mandates; and diffusion of power among consumers, states and businesses rather than concentration in Washington.

After Obamacare, we can stop pretending that a handful of experts in Washington know better than the rest of the country. After Obamacare, we can return to debating solutions more in line with traditional American values and American ways of solving problems by the trials and errors of a free people. After Obamacare, the goals will be more modest, but more realistic. After Obamacare, health care reform will still be possible – but only if President Obama abandons his utopian schemes and looks at the kind of solutions that Americans have long regarded as common ground.

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