These two tweets tell you all you need to know about the politics of health reform

Two of Avik Roy’s tweets yesterday, pertaining to the recently released Senate GOP health reform plan (the Patient CARE Act) and discussion thereof, are very revealing.

I do not mean “revealing” in a gotcha or gaffe sense. In fact, I largely agree with Avik. Repealing the ACA is not necessary to further a conservative health policy agenda. Therefore, as Avik correctly points out, it’s unnecessarily disruptive to do so. Yet this is what the Patient CARE Act does. And then it, in some ways, replicates some of the structure of the ACA, though in other ways it departs from it. (See Don Taylor’s summary.)

This is precisely why I’ve responded to journalists’ inquiries about the Patient CARE Act by pointing out, among other things, that it’s clearly designed to serve the objectives of the campaign(s)—2014 and then, perhaps, 2016—not as an effort to engage in good faith negotiation with Democrats on health policy.

This gets to Avik’s second tweet. I think it’s overly broad, but still suggests a good point. Good faith policy making in the realm of health care is not going to happen anytime soon. And the reason isn’t that the ACA and the Patient CARE Act couldn’t be reconciled—they’re similar enough that a nip here and a tuck there and compromise isn’t too hard to fathom. (See this other Don Taylor post.) The reason is purely political.

title 1-repeal

Title 1 of the Patient CARE Act repeals Obamacare to provide “needed relief from job-crushing mandates.” That’s all it does. That’s its sole purpose—on paper. But Title 1 isn’t really there, on paper, to repeal Obamacare. It’s there to satisfy the need of GOP candidates to appear to be against everything actual and implied by Obamacare on the campaign trail and in primary debates, if not those for the general election. It’s there so that more moderate GOP Senators and Representatives can say they have a reform plan, but still minimize the risk they’ll be challenged on the right by a Tea Party candidate who is “really” for repeal.

Meanwhile, Democratic candidates, by and large, cannot be for repeal. Obamacare is their law, and explicitly so if they voted for it. Therefore, it hardly matters if the Patient CARE Act is similar in many ways to the ACA. No Democrat can be for anything that begins with repeal no matter how similar the guts are to the ACA (whether initially or after some compromise). That’s admitting political defeat on the ACA and handing victory to the GOP. Why would Democrats do that?

They won’t. They won’t today. And they won’t after the midterms. There’s no compromise here. One side needs to be for repeal, for political reasons. The other side cannot be, again for political reasons. Yes, there are also policy reasons to be for or against repeal, but those could easily be reconciled by negotiating on the underlying policy preferences. That’s a theoretical possibility, but not in the political context.

The two sides cannot be reconciled right now or soon. (Don Taylor is more optimistic.) The best bet for health policy compromise, in my view, is if the GOP sweeps in 2016. It is hard for me to believe they would actually repeal the law in that case without implementing a substantially similar replacement. Nothing of the sort could happen before 2018 anyway.* And by then, four years after full implementation of the ACA’s insurance reforms, as well as many years into its payment and delivery system reforms, far too many people and stakeholders will be invested.

What could happen in 2018, under a unified GOP government, is something called “repeal and replace” that alters the landscape a bit, but not too much. It may not be viewed as completely benign by all parties, but it won’t be a complete gutting of Obamacare either in anything but name only. Meanwhile, some moderate Democrats will likely go along, and will certainly be interested in negotiating. If the GOP controls the government and is unified in purpose, there’s no stopping them anyway.

Conservative means to progressive ends is the best bet for evolution of health policy. That’s how we got a Medicare drug benefit. And, despite the howls of protest, that’s how we got the ACA. It may not be conservative enough for 2014, but it’s not that far off either, if the Patient CARE Act is any guide. By the time the GOP could actually gut Obamacare, they won’t, despite the rhetorical packaging and campaign promises.

But that time is 2018, not sooner.*

* Legislation passed in 2017 is not likely to be implemented until 2018.


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