Apples and No Apples

There are two must-reads today I’d like to recommend. One is a long post on the intramural arguments in the U.S. environmental movement that are now exploding in the controversy over fracking (by Jason Mark at TAP; I’ll probably post about that later). And the other is Ezra Klein’s Wonkblog effort to take the “conservative alternative to Obamacare” seriously by addressing its elements, which is hard because it is often vague and does not enjoy united support.

Using an eight-point agenda identified by conservative writer Ben Domenech, Ezra makes this crucial distinction:

This isn’t a plan to “replace Obamacare.” It’s a plan to do the opposite of replacing Obamacare. It’s as if I said I had a plan to fix the house by replacing the leaky roof, and you said you had a plan to fix the house by getting rid of the roof.

The confusion here is the term “replace Obamacare.” Obamacare is, at its heart, a policy to make sure most every legal resident of the United States has access to comprehensive, affordable health care. In order to achieve that goal, it helps poorer Americans pay for insurance and regulates the products offered by insurers to make sure they’re worth paying for.

The eight-point program Domenech lays out is not an alternative approach to achieving the same goal. It’s actually an effort to achieve an almost perfectly opposite goal. Rather than make comprehensive insurance more accessible through government subsidies and regulation, it makes insurance stingier and rarer by removing government subsidies and regulation.

It’s a plan, for instance, to save money by making it so fewer Americans have access to comprehensive, government-provided health care. It’s a plan to cut costs by letting insurers offer far stingier, far higher deductible policies than they do today. It’s a plan to limit the ability of injured patients to sue. It’s a plan to hand Medicare over to private insurers. It’s not repeal-and-replace so much as repeal-and-do-something-else-entirely.

The Republican plan, as explained by Domenech, wouldn’t just mean fewer people with comprehensive health insurance than under Obamacare. It would likely mean fewer people having comprehensive health insurance than under the status quo. Perhaps that’s a good thing. A key conservative belief in this debate is that insurance products are much too comprehensive and the market should be rebuilt around high deductible and catastrophic plans. But it’s undeniably a very different thing. Obamacare and the Republican ideas aren’t even apples to oranges. They’re apples to taking away apples.

This is what I was getting at during the 2012 campaign cycle when I insisted that the GOP’s “repeal and replace” agenda could better be described as “repeal and reverse.” Conservatives have a beef not just against Obamacare, but against the features of the status quo that expand coverage, spread risks, and utilize public leverage in efforts to hold down costs.

Ezra’s analysis of what the “eight-point plan” would actually accomplish illustrates this point abundantly. This section on the “interstate insurance sales” bauble is especially important because it is do rarely discussed by anyone other than it proponents:

Of all the health policies in the conservative arsenal, this one commands the most unanimity among elected Republicans, and is also the most baffling. It forgoes the benefits of federal regulation while simultaneously rejecting the benefits of federalism. It’s straight race-to-the-bottomism. Permit me to crib a little from a previous post I wrote on the subject.

Insurance is currently regulated by states. California, for instance, says all insurers have to cover treatments for lead poisoning, while other states let insurers decide whether to cover lead poisoning, and leaves lead poisoning coverage — or its absence — as a surprise for customers who find that they have lead poisoning. Here’s a list (pdf) of which states mandate which treatments.

The result of this is that an Alabama plan can’t be sold in, say, Oregon, because the Alabama plan doesn’t conform to Oregon’s regulations. A lot of liberals want that to change: It makes more sense, they say, for insurance to be regulated by the federal government. That way the product is standard across all the states.

Conservatives want the opposite: They want insurers to be able to cluster in one state, follow that state’s regulations and sell the product to everyone in the country. In practice, that means we will have a single national insurance standard. But that standard will be decided by South Dakota. Or, if South Dakota doesn’t give the insurers the freedom they want, it’ll be decided by Wyoming. Or whoever.

And in a conclusory graph, Ezra gets at the real nub of the issue:

The Democratic vision is that every American should have be able to get pretty comprehensive health insurance. The Republican vision, as articulated by Domenech, is that health insurance should be less comprehensive than it currently is, and the federal government should be doing less to help people afford it. Or, to put it differently, Obamacare is trying to solve the problem of too little insurance. The Republican ideas are trying to solve the problem of too much insurance.

I’ve suspected for years that conservatives ultimately want to return our health care system to the pre-insurance days when people paid for medical care out of their pockets. Whether you buy that or not, it’s very clear anyone who likes some features of Obamacare but dislikes others, and dislikes the idea of no publicly guaranteed coverage at all even less, is in for a rude shock if the GOP gets its way.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.