Has Obamacare poisoned the well for all health policy reforms?
This article originally appeared on heartland.org.
The widely accepted view among policymakers in Washington, DC is that even if President Barack Obama’s health care law is currently more unpopular than ever, by the time 2016 rolls around, it will be an immovable object, impossible to wholly repeal.
I have previously argued this is an incomplete picture of the politics of the issue, one that underestimates the Republican base’s dedication to repeal and the necessity of Republican candidates to respond to that desire.
You could assume the continued unpopularity of Obamacare would play to Republicans’ advantage within the battle over health care policy, and that’s certainly correct at the moment. The fact that a Democratic Senator touting his support for Obamacare (albeit without naming which law he voted for) is national news is an indication of that. Had the politics of the Affordable Care Act played out as most Democrats anticipated, every candidate up for re-election would be loudly trumpeting their support for it.
So in the short term, the law plays into the hands of Republican critics, who have plenty of easy targets and little need to propose a comprehensive reform. But what about what comes after 2016, assuming a Republican presidency but lacking 60 votes in the Senate? At that point, Obamacare’s political toxicity may actually hamper efforts to achieve pro-market reforms.
Consider Avik Roy’s recent proposal, Transcending Obamacare, possibly the most comprehensive proposal for health reform offered by a conservative. It is more ambitious than other reforms: Not content to focus merely on replacing Obamacare, Roy’s plan relies heavily on the expansion of the existing private insurance marketplace as a replacement for the Great Society, shifting individuals away from Medicare and Medicaid and the VA, and toward private insurers.
While Roy’s proposal is certainly more conservative than Obamacare, it is also very centrist. It relies on the Democratic acceptance of the exchange + subsidies model via the ACA as a method of eliminating the nation’s current single-payer systems. In the absence of Obamacare, it is the sort of proposal that ought to receive significant support from moderate Democrats – Joe Manchin, Mary Landrieu, and Mark Warner all ought to approve of an approach that retains community rating and guaranteed issue. And in an alternate universe where the reconciliation process was never deployed, you could see many Republicans viewing this as a positive and comprehensive reform of the existing health care entitlement system, increasing personal responsibility and rolling back government’s regulatory dominance of the marketplace.
Except this is not the universe we live in. Instead, we live in one where Obamacare has become synonymous with a number of steps health policy wonks on both sides of the aisle have long favored. So the question now is: How much will the unpopularity of this law spill over to prevent the deployment of similar steps as a method of reform?
The most critical area where this question remains unanswered is on the subject of exchanges. While Roy’s reform eliminates the most unpopular aspects of the law – the majority of its mandates and taxes – its reliance on an exchange could prove to be a politically difficult sale. Consider the most recent poll data from The Morning Consult: It found, “A majority of people are worried about employers moving them on to insurance exchanges, with Republicans reporting the highest level of concern at 72 percent.” And: “The majority of Republicans and Independents say they would consider looking for another job if they were shifted onto an exchange, at 62 percent and 52 percent respectively.”
For a Republican candidate, these numbers demonstrate the political challenge of proposing an exchange-based reform. If more people are receiving their coverage through their employers than was true before Obamacare’s passage, proposing these exchange reforms could prove politically challenging, even for Republicans who want to roll back regulations and transform them into more open marketplaces.
Roy’s assessment is based on an assumption that no Republican presidential candidate will be able to successfully campaign on taking insurance away from millions of Americans. But the challenge of proposing an alternative that takes on the Great Society using approaches the Republican base closely associates with Obamacare may prove to be just as difficult.
Most Americans and most conservatives do not understand that America’s health care system was not a free-market system prior to Obamacare. Ultimately, the reforms they support may be more modest in aim, as the safest place for many Republicans is to argue for rolling back the clock to before the ACA’s passage. If that’s where the Republicans end up, it would mark a major missed opportunity to address the pre-existing failures of government-run health care in America. But addressing those failures in an environment where Obamacare has sucked up the oxygen for almost eight years will require navigating a minefield of public opinion – a task challenging even for skilled politicians.