• Are Republicans really anti-exchange?

    The following are all quotes from the paper “Pascal’s Wager: Health Insurance Exchanges, Obamacare, and the Republican Dilemma,” by David Jones and Jon Oberlander (forthcoming in the Journal of Health Politics, Policy and Law, February 2014).

    • “In a June 2010 Kaiser Family Foundation survey, 87 percent of all respondents—including 77 percent of Republicans— said they had a very or somewhat favorable opinion of exchanges.”
    • “62 percent of self-identified Republicans had very or somewhat favorable opinions of exchanges in a December 2011 poll.”
    • “[N]ine of the seventeen states that eventually decided to operate state-based exchanges had either a GOP governor or a Republican majority in at least one house of the legislature when the decision was made.”
    • “Strikingly, the only state with a Republican governor and Republican-controlled legislature that chose to create its own exchange— Idaho—is by at least one measure the most conservative state in the country.”
    • “[A]pproximately 90 percent of Republican legislators in Nevada and Hawaii voted to establish exchanges, as did more than 90 percent of Republicans in the lower chambers of the Alabama, Missouri, and North Carolina legislatures.”
    • “If we count only post-ACAvotes in states where legislators in at least one chamber voted, 42 percent of Republicans voted for exchanges through February 2013.”
    • “[I]nsurance exchanges drew relatively little fire from Republicans during the 2009–10 health reform debate. Moreover, prominent GOP leaders supported the concept even as they fought for the ACA’s repeal. Senator Coburn (R-OK) (2011), for example, continued to back ‘state-based efforts to create free-market, voluntary health insurance exchanges,’ though he distinguished them from the ACA’s ostensibly more onerous exchanges.”

    You can read the paper yourself and draw your own conclusion. My view is that Republicans are not generally, ideologically opposed to exchanges. Deep down, I think any pro-market health reformer knows exchanges are sensible. Consequently, at least some of the broad structure of the Affordable Care Act should be appealing to conservatives. To the extent elected officials most sympathetic to right-of-center health policy aren’t behaving accordingly, there would seem to be a disconnect between policy preferences and political tactics.* As I tweeted earlier this week:

    * Just so you don’t have to, I will accuse myself of putting it mildly.


    • I don’t see why this is so hard to understand. Conservatives aren’t against exchanges as a mechanism to purchase insurance. At all. They like the idea and have advocated for it. They don’t like heavy Federal-level requirements for what the insurance products must cover and the ACA’s framework to impose those requirements.

      The Heritage Foundation explained this in a 2010 WaPo editorial.


      It’s all over their website. It’s in countless other editorials and opinion pieces by those on the right.

      A much more interesting question than the one you provide is: what about the ACA would need to be changed so that it represents the state-based model advocated by conservative think tanks? Is that transformation possible without repeal?

      • I consider myself on the right/libertarian side. I have always believed that the exchanges are a sensible creation, as you put it. I’m strongly in favor of transparency and comparison shopping. I’m not convinced that the market can provide that kind of tool. This was determined independently, not by reading right-leaning opinion pieces. I also agree that the individual mandate is an economic necessity.

        However, that doesn’t mean the mandate’s constitutional, and I oppose it for that reason. I also agree with RC’s comments, these two major components of the ACA aren’t the reason I’m opposed to the ACA. It’s exactly because of all the new regulations, requirements, price controls, that I oppose it.

        • Actually the web site ehealthinsurance.com provides a pretty decent market for comparing plans, although I do think it can be a bit superficial in terms of the details of plan comparisons. Seems to me like that might have been worth building on.

    • I think the GOP rejoinder would be that they want exchanges formed by the private sector. The problem is that private insurers have never had much incentive to form these. That said, I fail t see why an exchange formed by the govt, one that is an open market with no coverage requirements, would be opposed by conservatives.


    • Controversy surrounding the ACA exchanges provides a case study in how political opposition should never be misconstrued with ideological opposition.

    • P.S. Republicans profess to want an exchange system for Medicare.

    • I wonder how you define conservative?

      1)Less government vs more government
      2)Constitutional interpretation
      3)Fiscal responsibility
      4)The Tenth Amendment
      5) Though most that are not to the left are considered conservative there is a vast spectrum of beliefs that separate conservatives into distinct groups. That might be hard to understand if one looks at things from a leftist ideology.

      Basic principles do matter.

      • 73% number 1 + 22% number 4 + 5% unclear

        “That might be hard to understand if one looks at things from a leftist ideology.” <-- Unhelpful and not appreciated, but thanks for the question. UPDATE: 53% number 1 + 21% number 3 + 21% number 4 + 5% unclear. But note that 1 and 3 are not uncorrelated. UPDATE #2 (can't help myself): Simpler would be to define a conservative as 100% #5. 🙂

        • I wasn’t referring to you or anyone else as a leftist so I am sorry for the way you interpreted what I said. I was pointing to the fact that the left is a more unified voice so many might not recognize that there are significant differences among those not considered on the left. That would include many Republicans. You are interesting because though you are further to the left than me I find some of your thinking processes to be quite ‘conservative’ crossing ideological lines. I am personally not particularly impressed with either party.

          (Unified Conservatives? No.)
          Take the Tea Party that demographically is fairly mainstream. http://www.gallup.com/poll/127181/tea-partiers-fairly-mainstream-demographics.aspx They are considered Republicans and conservatives (They have substantial disagreement with Republican leadership). Take the view of those where religion and abortion are the most important political points. They are considered conservatives. Look at the libertarians that are considered conservative as well, but even there libertarians can be divided into significant groups where one of those groups that might consider themselves libertarian are classical liberals. Can I call the broad views of conservatives disorganized? Can I state that the views of the left are more organized?

          Your numbers are quite interesting and demonstrate that the only major distinction you see between conservatives and everyone else is a desire for less government. I see a much greater difference from what I believe to be a more classical liberal view point. At this juncture I don’t even like the term conservative. I don’t think William Buckley who is considered the father of the modern conservative movement would agree with your numbers, but he is dead and you are alive. That, however, demonstrates the reason for so much confusion about all of these labels.

          • “I was pointing to the fact that the left is a more unified voice [than the right].”

            This is not the conventional wisdom, such as I know it. The broader, more diverse, left-leaning coalition that the Democrats traditionally cobble together is one reason why, historically, their primaries and conventions have been more drawn out and chaotic. People often point to this to explain the (historical) ability of Republicans to stay “on message” better than Democrats. Personally, I’ve noticed that one’s ideas are not accepted on the right (even if they’re conservative ideas) if one does not demonstrate a kind of purity that I do not perceive as necessary on the left. This last point is anecdotal, but not unique to my own experience. Many people have corroborated my observation that liberals seem more willing to tolerate different points of view and criticism of even liberal ideals.

            Maybe the relative unification of voice has changed or is in the process of changing. I’d buy that. But I’d say that’s more due to a diversification on the right than a homogenization on the left. Perhaps that’s what you’re referring to.

            • I see some of our differences are definitional and may not be real. I don’t believe you are a leftist. You certainly aren’t a far leftist. The true left represents only the smaller portion of the Democratic party, but the leftists have drawn the party far to the left of where a JFK would stand if he were alive today. You are correct that the Dems have more raucous conventions than the Republicans historically, but that is because the old guard Republican determines who is ‘next in line’. To me that is a very significant problem in the Republican party.

              I don’t believe the Republican party itself represents the classical liberal, fiscal conservatives, libertarians, the Tea Party, Constitutional textualists, etc. though they might vote Republican. Obama won because those on the Republican side refused to vote.

              “Personally, I’ve noticed that one’s ideas are not accepted on the right (even if they’re conservative ideas) if one does not demonstrate a kind of purity that I do not perceive as necessary on the left.”

              I would agree, because the old guard Republican controls the party, but they are far from pure ‘conservatives’, at least when compared to the conservative Republican of the early days. I don’t like these terms that we use and I am as much at fault as everyone else. I like to deal with specific issues and specific principles.

              My game is we both want the needy to have quality health care with good access at reasonable cost. How do I get there without violating my principles which you might believe are off the chart, but they aren’t. They follow market principles that have made us wealthy while not denying us our individual freedoms. My guess is your political voice is far from mine, but your intellectual voice is much closer and recognizes markets and individuality. We both have to be careful of the trap set for us by what some believe to be our political views some of which we are afraid to deviate from because of those we associate with.

              I developed a set of principles long ago, but that doesn’t stop me from caring for my neighbor. I also learned that those principles worked out best for my neighbor and those that were suffering who frequently are one and the same. Maybe in the future when we discuss things we should eliminate the political terms and use principles, but I am afraid I might be first to violate that rule. I find that politics causes unfriendly debate whereas dealing with principles leaves two people either agreeing or disagreeing with the principle, but no animosity.

              “Many people have corroborated my observation that liberals seem more willing to tolerate different points of view and criticism of even liberal ideals.”

              I won’t debate this at this time, but obviously I strongly disagree and I believe that disagreement is documented in every day affairs.

    • Actually there’s other parts to the ACA that generally stem from various conservative/free market ideas. For quite some time it’s been popular on the right to support tax credits to allow people to buy health insurance (usually either as a full replacement for the tax exemption of employer-based health care, or making it available to people without employer provided care), and high-risk pools have long been a favorite among the think tanks.

      That said, people who point at Republicans and accuse them of sheer partisanship in opposition (or racism) because they in the past have supported some similar elements overlook the simple fact that just because Frankenstein’s monster was built from parts designed by God, doesn’t mean that God should approve of the monster (not trying to get preachy, just seemed like a good analogy). The fact that parts of Obamacare resemble things that some conservatives and free-market types have promoted in the past says nothing about whether they should support the particulars of this bill.

      • Totally agree with you Sean. I’d just like to see the critics acknowledge the aspects that they believe have merit, at least in broad design. Every time I turn to another conservative reform proposal I see huge overlap with the ACA. Yet, it’s couched in language that trashes the entire law: “repeal,” “monstrosity,” “train wreck,” “albatross,” and the like. Not helpful, except politically, in my view. Just saying.

    • The Republicans are anti anything they haven’t thought up themselves, or that doesn’t promote their agenda.
      I thought Romneycare was a good workable ACA option for the State of Massachusetts, and from what I understand the Obama ACA, based heavily on the Romneycare model, is now deemed anathema to most Republicans – why?
      If it was OK on the State level, why not on the Federal level, could it be politics at work ?

    • Why not let the Fed Gov?

      This is the quick fix route.. just let some smart person… some elite.. someone who knows better than the people.. figure out what we all need. I mean it looks so good on paper. We don’t need to worry about it then, right? Just give them the power.

      The issue is concentration of power. Lack of accountability. Lack of anything in the game. The Fed gov presides over >300M people. Meaning it is a very very very small group of elites. How can it be in tune with local communities. How can it innovate and adapt to the global economy/dynamic.

      We need to all be involved.. all need to be working this stuff out on a local/state level where there’s accountability and more direct feedback.

      Concentration of power is the scariest. What happens when the wrong person meets the perfect crisis? Power corrupts. Should we be willing to take the chance?

      It seems the Founders tried to their best to distribute power amongst states and branches of gov. I think they were right.

    • Nice mixed metaphor in that tweet – pedigree with chassis!

      Conservative = Fiscally responsible? Maybe in ideology, but not in practice. Please refer to one Ronald Reagan . . .George W Bush . . .

      • Zenospinoza, Ronald Reagan had to deal with Congress. Additionally investment is considered fiscally conservative. RR invested in tearing down the Berlin Wall and the Soviet Union fell without the use of any bullets or bombs. That was a very good investment.

        George W. Bush was not a fiscal conservative. Take note of the Medicare Part D entitlement.