Wisely, Avik Roy has joined Paul Howard and Yevgeniy Feyman in recognizing that the Affordable Care Act (ACA) provides a solid foundation for right-of-center reform.* It seems that, at least among some conservative policy analysts, repeal is dead, even as a campaign slogan.
Avik is right to suggest that embracing the ACA will seem jarring to those hitting the GOP campaign trail this year, even if it offers what they might interpret as advantages.
Given that conservatives have campaigned on repealing Obamacare for nearly four years, it’s jarring to consider a reform plan that does not formally scrap the law. But such a plan has several advantages.
First, it is far less disruptive to the existing system because it uses a deregulated version of Obamacare’s exchanges to gradually replace our legacy Great Society entitlements. That makes it more politically viable than repeal. Second, it takes advantage of the Obamacare exchanges’ best feature: Over the long term, exchange subsidies will only grow at the rate of inflation, a rate that is significantly lower than the growth of our existing health care entitlements.
As Avik points out, a necessary condition for working with, rather than against, Obamacare is for conservatives to embrace universal coverage as “a morally worthy goal.” On Twitter, Adrianna characterized this as the key to honest intellectual debate.
I’m simultaneously more cynical and practical. First the cynical: we’ll never have honest intellectual debate.
Can Avik and I have an honest intellectual debate about whether Medicaid helps or harms people, about whether Singapore’s low health spending is due more to the nature of its insurance and provider markets or to government intervention in them, about whether raising the Medicare retirement age is a helpful cost control step? He’s as familiar about my views on these issues as I am about his. We’ve gone back and forth on these issues for years, and I’ve never come close feeling like we have had an honest intellectual debate. My guess is that he hasn’t either, though he can correct me if I’m wrong. Yet, I bet we both likely feel that we, ourselves, are engaging honestly with each other and the evidence.
Next, the practical: we don’t need honest intellectual debate. It’s neither necessary nor sufficient for health policy progress.
For all the intellectual disagreement (and dishonesty!) among wonks and pols, we could still make progress. For example, both Avik and I recognize that the ACA is a foundation on which to build additional reforms. And, as I have argued, even if some of those reforms take a rightward direction, liberals should engage conservatives on them, for some things of value could be gained in an exchange. What’s needed is not honest intellectual debate, but good-faith compromise.
For, even if we could have an honest intellectual debate, we will still not resolve differences in our policy preferences. Indeed, if we’re completely truthful with ourselves, we will recognize that those policy preferences drive our marshalling and presentation of the evidence. That being the case, no amount of honesty in discussion of it will flip Avik’s policy preference or mine.
It comes down to values. Those differ, and they always will. They cannot be debated away. But both sides can advance their values through exchange. Neither side will fully win, and neither will fully lose.
I’ll take good-faith compromise over honest intellectual debate any day. The latter will never happen. Unfortunately, I’m only slightly more optimistic that the former will, even if rarely, briefly, and not, among pols and their surrogates, in an election year.
UPDATE: Clearer language about my perception of the intellectual honesty (or lack thereof) of my debates with Avik.
*Earlier and similar sentiments were expressed by Avik here.