Backed into a corner

I was walking to the office while reading today’s Wonkbook, and I was struck by this:

Conservative elites had two options when Democrats began to adopt their policy ideas: Declare victory or declare war. Key figures like Gingrich could’ve stepped before the cameras and chortled about Democrats giving up on single payer and slinking towards conservative solutions. For Hillary Clinton to run in 2008 with Bob Dole’s health-care plan was an amazing moment in American politics. For Barack Obama to reverse himself on the individual mandate and embrace the Heritage Foundation’s approach to personal responsibility was further proof that Democrats had lost the war of ideas here. Republicans could have declared victory and, by engaging constructively, pushed the final product further towards their ideal.

They chose war instead. And that meant eradicating any trace of support for the policies they had come up with.

That effort was extraordinarily successful. Republicans quickly convinced themselves they had always been at war with Oceania — excuse me, the individual mandate. But plausible health-care plans are hard to come by. Even the plans that weren’t exactly like Obamacare were too similar to Obamacare for comfort. And so, five years later, even leading Republicans haven’t really come by another one. There’s a gaping hole where the party’s health-care plan is supposed to go. Of course the public doesn’t trust Republicans on the issue. Republicans don’t even know what they’d do.

I am sure there will be an outcry from conservative wonks about how there is, there really is, some secret Republican health care plan. But a health care plan that gets a couple more people insurance, or allows people to buy insurance – but at a massively huge premium, or that does nothing to increase access isn’t a comprehensive health care reform plan. Sorry.

The biggest problem, and one that few Obamacare opposers will confront, is that the ACA is a relatively conservative solution. It’s not a government system, like the VA or the UK’s. It’s not a single-payer system, like Medicare or Canada’s. It’s not even a universal public system with a private overlay, like France’s. It’s a massive expansion of private insurance and Medicaid with an individual mandate and subsidies. It’s Romneycare writ large. It’s right out of Heritage Foundation’s playbook.

By eliminating that as anything even remotely acceptable, conservatives have eliminated almost anything that might work. This isn’t magic. Contrary to the pundits who like to say over and over that we have no idea what we’re doing, we have massive amounts of data on how different health care systems work. There are tons of different systems all over the world. The one thing we do know is that our system leads to the highest costs, one of the lowest levels of coverage in the developed world, and shockingly middling quality.

But where to go now? Evidently, a new plan is “on the horizon”. We’ll see; we’ve heard this before. But with one of the most promising workable conservative solutions rendered radioactive, there’s not much left.

That’s how you get conservatives advocating for a decoupling of insurance from employment. Guess what? Liberals like that too. There’s enough of a consensus around that to have created the Wyden-Bennett plan, which had massive bipartisan support, before mandates, exchanges, and subsidies became tyranny. That support cost Senator Bennett his job.

That’s how you get conservatives advocating for “SwissCare”, while ignoring that Switzerland has an individual mandate, more regulations, price fixing, and lower caps on out of pocket spending.

That’s how you get conservatives advocating for Singapore’s health care system without any real understanding of it. Singapore’s system has massive subsidies for nursing homes, rehabilitation care, and home-based care. It requires mandatory savings – 36% of wages spread over various accounts. The government also provides a basic level of care that’s heavily, heavily subsidized. And here’s the kicker – it relies on tons of government intervention in the market to keep costs down. They use centrally planned and fixed budgets, they control the acquisition of new technology, they regulate the number of students and physicians, they use purchasing power to buy drugs more cheaply, they have an employer mandate for foreign workers,and  they have a national EHR. They’re also not the most open society in the world.

Here’s the thing. I bet you could find lots of liberal wonks, and lots of Democrats, who would be fine with much of the above. You want Swisscare? Great. You want Singapore? OK. The problem is that’s not what’s offered. It’s Swisscare, but without a mandate. Guess what? That’s doesn’t work – that’s why Swisscare has a mandate! They suggest Singapore, but without the mandatory savings, public hospitals, and government management. That doesn’t work – that’s why Singapore has those aspects.

It’s the three-legged stool writ large. These systems all function because they contain stuff people like and stuff they don’t. It’s part of making a working health care system. You can’t have guaranteed issue and community ratings without some sort of means to nudge healthy people into the pool (mandate) and some sort of means to help people at the lower end of the socio-economic spectrum afford care (subsidies). The Heritage Foundation knows it, Governor Romney knows it, and Speaker Gingrich knows it.

If you’ve destroyed the tools available to make a system function, you can’t expect it to work. Prove me wrong.


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