• Health care reform and the primary: this ain’t 2007

    I’ve been arguing, and I’ve seen a lot of pieces arguing, that health care reform and the Affordable Care Act are going to be a big part of the next election. Yet, there have been few real arguments between the candidates in the Republican primary as to what they would do, other than repeal the ACA. I’m struck by how different this primary seems to be than the last one.

    For instance, in an effort to separate himself from the other candidates in the primary race of 2007, Senator John Edwards released a detailed plan in a 12-page booklet in early 2007. That would have been the equivalent of early 2011 in this race. Here’s an article by Christopher Lee from the Washington Post in March, 2007:

    Edwards has so far staked out the most detailed position. His plan would require employers to provide health coverage for workers or pay a portion of their payroll into a fund that would help individuals buy private insurance through new regional health-care purchasing pools. He would also expand Medicaid and the state-federal Children’s Health Insurance Program, and would provide tax credits to help make insurance more affordable for lower-income families.

    Most of the $90 billion to $120 billion annual cost could be paid for by eliminating President Bush’s tax cuts for households earning more than $200,000 and by increasing Internal Revenue Service efforts to collect unpaid capital gains taxes, Edwards has said.

    Tim Noah, who did phenomenal work in the primary that year on health care, had a detailed piece, which was written in July of 2007, on Edwards’ plan.

    Senator Obama offered his comprehensive health care reform plan on May 29, 2011. Once again, there was Tim Noah with a detailed analysis, published on June 19 of that year:

    Market gimmicks: Obama would establish a National Health Insurance Exchange that would create “rules and standards for participating insurance plans.” Anyone could buy private health insurance through this exchange, and presumably be guaranteed a certain price (on a sliding income-based scale) and a certain breadth of coverage. Participating insurers would not be permitted to exclude less-desirable (i.e., sick) customers. This scheme is based on the new Massachusetts health-care plan signed into law by former Gov. Mitt Romney, who is seeking the Republican nomination. As a presidential candidate, Romney himself previously distanced himself from the plan, but at a June 5 debate he managed to tout it (“The market works. Personal responsibility works.”) without saying “Massachusetts,” a word his advisers have urged him to avoid. The National Health Insurance Exchange isn’t very gimmicky, but I’m not convinced it would be very effective. (It’s too soon to know how well it’s doing in Massachusetts.)

    Read the rest. Fun fact: it uses the word “Obamacare“!

    That left Senator Clinton looking like she was waffling. She released her plan on September 17. Tim Noah had the details on September 20. Here’s Paul Starr on September 24.

    And, for months, the candidates argued over the details. Here’s mid-November coverage on a debate that details the minutiae the candidates discussed with respect to health care reform:

    In one of the liveliest exchanges of the Democratic debate last night, Senator Hillary Rodham Clinton said that Senator Barack Obama’s health care plan “would leave 15 million Americans out.” That, Mrs. Clinton added in an ominous nod to the early nominating states, is “about the population of Nevada, Iowa, South Carolina and New Hampshire.” Mr. Obama countered that “the fact of the matter is that I do provide universal health care.”

    The crux of their dispute centers on their overall approaches to health care.

    Mrs. Clinton’s plan would require all Americans to get coverage and would provide subsidies to make it more affordable. Mr. Obama’s plan would require only children to have coverage; his plan would require employers to provide coverage or contribute to a new public program that would make insurance more affordable to people not covered by their jobs or by the government.

    Two weeks later, they were still “slugging it out” on this issue.

    That was more than four years ago today. I’ve watched a number of Republican primary debates at this point, and I’m not seeing this kind of focus on the details of health care reform. Sure, we know that all the candidates agree that the ACA has to go, but I’m not seeing much more in terms of what they will do once they get that done. Sure, health care reform gets mentioned, but it’s not vigorously debated.

    I’m not blaming the candidates for all of this. They can’t control the questions in the debates, and so they can’t be blamed if the debates don’t focus on the issue. It’s also possible that the American people aren’t as interested in the topic this time around.

    I don’t think that’s true, though. I think that health care is going to play a huge part of this election, especially given the upcoming Supreme Court decisions. At some point we have to get beyond “repeal” and have a real discussion of what the candidates will do after that. The amount of detail released, discussed, and debated in 2007 was immense compared to what’s occurring in 2011. Last time around, primary voters seemed to be demanding more information from their candidates. I’m somewhat surprised that this time around, it doesn’t seem to be happening.


    • I have said many times that the GOP just is not that interested in health care reform. We may get repeal, but I will be shocked if we get replace. I think the lack of focus on the issue reflects their lack of interest. Several of the debates have been conducted by conservative questioners and it was not an important issue.


      • In all fairness to Republicans, the reason they don’t care about health care policy is because they don’t care about policy.

        Consider the experience of Paul Ryan, now marketed as Mr. Financial Responsibility, but, because he’s a Republican, he voted with Pres. Bush 94% of the time. That included Medicare Part D, voting against making it more cost-effective, the Bush fiscal policies, No Child Left Behind, TARP, the USA PATRIOT Act, and the invasion & occupation of Iraq.

        Now he claims to care about the deficit and about excessive federal & executive power. But he’s a Republican, and he’s been a Republican for the past decade, so we know that he doesn’t care about those things.

        Being a Republican is a matter of tribal affiliation. Policy preferences and priorities change depending on tactical and emotional considerations.

    • I can’t imagine it takes a great leap of imagination to view the GOP’s health care reform as only a reactionary priority in general. As it relates to Republican presidential candidates, the only health care reform priority now is a repeal of the ACA because that’s what the Republican base wants to hear. Yet, as I’m sure you’ve noticed, when asked for something a little bit more substantive than repeal they already have a stand-in framework for reform, thanks to Rep. Paul Ryan. The Democratic base demanded more from their prospective candidates in the ’07 primary because health care reform was more important to them than it is to Republican base now.

    • To the extent the GOP base cares about healthcare it goes just as far as “keep your government hands off my medicare.” For elected Republicans that means only the retirement benefits owed to workers under 55 will be robbed to pay for the Bush tax cuts. I don’t expect any Republican any time ever again to offer a serious proposal for how to insure all Americans; maybe someone from the next conservative party will offer a useful idea. For the rest of history Republican policies will never again cross the serious effort threshold. They’re that far gone.

    • I am deeply concerned that government health care costs will be a major focus of the campaign to the exclusion of all other health care issues (private costs, illness, disability, death). If the latter continues to be considered irrelevant,it will be extremely hard to fight for ACA or any meaningful expansion of health care and harder than it normally would be to fight against reducing costs by pushing them onto patients (e.g. Ryan Medicare plan).

      I’d be happy to have someone talk me off the ledge if they do not think the political discourse on this subject has gotten that bad.

      • @George
        I think the most likely option is talk only about what people are against. There is not likely to be any movement toward a replace plan.