Thoughts provoked by Philip Klein’s *Overcoming Obamacare*

Philip Klein’s Overcoming Obamacare provoked a few thoughts, some of which I list below. (See also Aaron’s post about the book.)

  • Separating possible conservative health reform ideas into Reform, Replace, and Restart schools of thought works (though imperfectly) as a policy exercise. I’m not sure it works politically. As Klein expressed, one can view “repeal and replace” as “reform” and vice versa.
  • The approach is imperfect because reform is multidimensional. Avik Roy’s proposal, which dominates the Reform School chapter, would preserve quite a bit of the ACA’s structure (relative to other approaches) but would not, over time, retain that of Medicare. On the other hand, a 2017 Project proposal, described in the Replace School chapter, would offer tax credits that vary by age, not income — quite a departure from the ACA’s approach. But, it would not change Medicare. Which is reform and which is replace? It depends what specific domain of policy you consider.
  • It’s likely that different politicians will find it advantageous to characterize the very same proposal in different ways, depending on their constituency. For instance, a Red state Republican may need to say that a plan repeals Obamacare (or else be out of a job upon next election). A Republican in a more moderate state, perhaps one with a large population relying on the ACA for coverage, may need to characterize it as retaining Obamacare but making some improvements. Any Democrat supporting a health policy change is likely to have to say the same. The actual proposal may not differ, but the characterization may need to. Can two apparently contradictory characterizations coexist politically? Or will some leverage one characterization to disrupt the message of the other? (Imagine someone attacking a Red state Republican as a fraud because the plan s/he says repeals Obamacare really does not, according to moderate Republicans in other states.)
  • I thought the discussions of which budget baseline, pre- or post-ACA, against which to measure health policy proposals was the most interesting dividing line. Anything measured against post-ACA can be viewed by some as caving to the budget preferences of the left. Anything building up from pre-ACA is, by definition a “repeal” approach, tend to be more radical (in the sense of deviating further from the ACA). I’m not sure how practical it is to budget as if the ACA didn’t happen, given the reality that we’ve been existing in a post-ACA world for five years (and will have been for over seven by the time any new reforms could be put in place).
  • Klein gets around to the real crux of the problem, which is bringing white paper proposals into the messy political fray and accommodating important stakeholders. Expect a great deal of turmoil and adjustment once a policy moves from the think tank conference table to the congressional committee room. What comes out may not look a great deal like what went in. My expectation is that it would move toward the Obamacare structure, not away from it. Why? Because Obamacare was shaped, in large part, by the same forces and stakeholders that will bear on anything that might come after it — hospitals, insurers, pharmaceutical manufactures, physicians and so on. And they have all become more, not less, invested. That’s not to say some change isn’t possible or desirable. It’s just to suggest that change as radical as some now promote is far less likely.
  • Governor Bobby Jindal’s idea that Republicans should be willing to take large political risks to reshape health policy strikes me as the wrong way to sell anything to politicians. Yes, Democrats did take political risks with the ACA, but I think they believed that they would turn into rewards as people came to understand, rely on, and like the law. That turned out not to play out as expected, but my point is that the push for health reform was not sold as a political risk, even if it was. To open with the idea that a party should plan on losing some seats over a legislative agenda — while noble and, perhaps, realistic — seems like a very tough sell.
  • As Klein notes, a lot could change in 2015. He is (and I am) thinking of King v. Burwell. If residents in more than half the states lose access to subsidies, that’s going to provide a lot more motivation for some kind of legislative action, but also a lot of opportunity for political grandstanding and obstruction. It’s also going to happen — if it happens — just as we’re entering the 2016 presidential campaign. I expect that will only make things messier and harder. But, recognize that things won’t change in many states, no matter the King v. Burwell outcome. Political actors from those states may not be as motivated for radical change as are those from states that lost access to subsidies. Why should Massachusetts, say, upset their apple cart to reshape health policy to Mississippi’s liking, for instance?

Overcoming Obamacare is a very useful summary of conservative health policy thought. There’s plenty in it I don’t agree with and some things I do, but that’s not the point. If you want to understand how some conservatives would prefer move the country in health care, it’s a worthwhile read.

Disclosure: Philip shared an advance copy of his book with me.


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