So if you’re getting a bit confused about the various “plans” kicking around as Republicans struggle to come up with a united front on what to do if they (or the Supreme Court) ever succeed in repealing or disabling the Affordable Care Act, the Manhattan Institute’s Avik Roy prepared a useful if highly argumentative set of comparisons at Forbes the other day. He’s mainly focused on explaining the new Patient CARE Act, a refurbished version of last year’s Burr-Coburn-Hatch bill that is being promoted by Burr and Hatch along with Rep. Fred Upton. But he also compares that proposal with his own, and with the Weekly Standard-backed 2017 Project proposal.
Roy clears up one feature of the new PCARE Act proposal that I was uncertain about when I wrote about it the other day: it does indeed include interstate insurance sales, which pretty much means the plan’s provisions deferring to state regulatory powers on various subjects are likely to become moot as insurers race to the bottom to incorporate in the state with the least regulation.
He also nicely identifies the major stress points dividing the Republicans backing different plans. One is whether they incorporate the Affordable Care Act’s Medicare savings–a.k.a. the “Medicare cuts” Republicans savaged on the campaign trail the last three cycles. It’s a lot of money. Another is whether they embrace “Medicaid reforms,” typically dumping the program on the states by gradually withdrawing federal support. Still another is the treatment of people with pre-existing conditions, which in some plans have the withered booby-prize of state-run high-risk pools offering terrible insurance at exorbitant rates, and in others have limited protections if they have “continuous coverage.” And finally, there’s the issue Roy considers potentially irresolvable: whether to make purchasing subsidies offered via the tax code means-tested:
An alternative approach—embraced by groups like the 2017 Project—prefers a uniform tax credit that would be the same for the poor and the rich. The argument advanced by the 2017’ers is that a uniform tax credit avoids the problem of discouraging people from making more money, because their subsidy is the same regardless of income. The means-tested approach, they say, discourages work by gradually reducing the subsidy as income goes up. Furthermore, many conservatives are inherently hostile to the principle of income redistribution, and therefore have an intuitive aversion to means-tested subsidies.
You can see here how the broader debate among conservatives over income inequality and wage stagnation has bled into the more specific debate over health care. If you are going to make the argument that means-tested public benefits are the single greatest impediment to maximum private-sector employment, then you obviously cannot set up a new set of such benefits under the Republican “brand.” But a uniform tax credit for buying health insurance will either be insanely expensive or will leave the most vulnerable people far worse off than they are under Obamacare.
Roy doesn’t look at every GOP plan, most obviously excluding Bobby Jindal’s, which adds even more discord to the debate by focusing almost exclusively on cost-containment at the expense of expanded coverage for the uninsured, corresponding with Bobby’s political argument that his rivals are peddling Obamacare-Lite. All in all, it’s very obvious GOPers are many miles away from agreement on a “replacement” plan, and even if the Supremes don’t force their hands in June, they’re running out of time.