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January 31, 2014 11:10 AM The Contradiction at the Center of GOP Health Care Policy

By Ed Kilgore

Many times and in many different ways, some of us progressive gabbers have tried to make the point that the Republican approach to health care policy consistently exhibits a central contradiction: seeking to mobilize constituencies who resist any change while favoring policies as (or more) disruptive than anything in the Affordable Care Act.

It’s been most obvious in GOP attitudes towards Medicare, which Republicans have fought to protect from “Obama’s cuts” even as they scheme to end it as a defined-benefit entitlement. The ludicrous figure of Paul Ryan posing during the 2012 campaign as a brave young man fighting to protect his mom’s Medicare benefits perfectly reflects the duplicity of his party on this subject.

But the contradiction has also been present in nearly every argument over health care reform. Republicans have very successfully exploited the grievances, real and imagined, of people who look at Obamacare and conclude they are not better off or resent being forced to change policies (often forgetting that pre-ACA policies and their prices were constantly changing, and rarely for the better). But all along, virtually every conservative health reform proposal, before and after ACA, included provisions wildly more disruptive than Obamacare, mainly because of a strong animus towards the existing tax subsidy for employer-based health insurance. No wonder Republicans have been reluctant to embrace alternatives, or even to talk about employer-based insurance (other than exaggerating every instance of a business reducing coverage for part-time employees because of Obamacare), instead focusing on the small individual market.

Now Republicans in Congress seem to be taking a good look at the new Coburn/Burr/Hatch “Patient CARE Act,” which is being cheered lustily by the small tribe of conservative health policy wonks, as an alternative they can finally embrace. But that’s mainly because it’s as complex as Obamacare, and also limits the attack on employer-based coverage (to use an automotive analogy, it runs the old system off the road instead of colliding with it head-on).

Today at TNR, Jonathan Cohn has the best take on “P-Care” so far in terms of its disruption of existing insurance arrangements. You should read it all, but here’s a key passage:

Another boast the Republican senators make is that their plan doesn’t raise taxes in order to finance the coverage expansion. Instead, it finances the coverage expansion primarily by reducing [the] tax break for employer insurance. But Republicans would typically call such a change a tax increase. (In conservativespeak, ending a tax break is the same as raising taxes.) And one likely effect of that reduction would be to put pressure on employers to make insurance cheaper by any means possible….
[E]mployers would respond by reducing benefits, narrowing networks of providers, or some combination of the two. Most likely, some people would lose employer coverage altogether. This isn’t necessarily a bad thing. Premiums for this insurance would be lower and the money not spent on health insurance would, over time, show up in workers’ paychecks. But the disruptions to employer insurance would be precisely the sort of changes that Republicans say they hate about Obamacare.

For the same (or more) disruption of the status quo as Obamacare, P-CARE would offer a lot less in exchange, other than the theoretical cost containment attributable to making the whole health care system less generous (more than offset, I’d say, by the refusal to insure health plans cover preventive care, and the refusal to “interfere” with provider decisions that boost costs). The childless poor people benefiting from ACA’s Medicaid expansion would be left behind entirely. So, too, would be those with pre-existing conditions who cannot maintain continuous coverage because it’s too expensive. The absence of government-established exchanges means a newly subsidized individual insurance market would become even more of a shark pool where consumers get regularly screwed. Here’s how Cohn puts it:

The Republican senators make a big deal about the flexibility their proposal would offer, because the federal government wouldn’t be establishing a set of essential benefits that all plans must cover. And for people upset about what those requirements mean under Obamacare—for example, older men angry about the higher premiums that come with newly mandated maternity care—this will be a big plus. But “flexibility” also means that carriers could continue to sell junk insurance policies—and that people could continue to buy them, only to discover those policies don’t provide the coverage they need. For many people, the Patient CARE Act really would mean cheaper insurance, just like the proposal’s champions say. But that’s because there’d be less security. “It doesn’t work if you’re poor or if you’re sick—other than that, it’s ok,” quips Jonathan Gruber, the MIT economist and Obamacare architect.
Flexibility would also mean that insurers could use benefit design to scare away people with high risks, since people with chronic conditions are unlikely to buy plans that won’t cover treatment for their diseases. And speaking of people with medical problems, the Republican senators say their plan would help people with pre-existing conditions. But the guarantee of insurance would exist only for people who maintain their coverage—something that, without sufficient financial assistance, some people would not be able to do.

All in all, P-CARE doesn’t live up at all to the conservative rhetoric about “patient-centered” health reform. But the more urgent political fact about it is that it’s as complicated as Obamacare, and would produce a lot more nasty surprises than all the Obamacare “sticker shock” and “rollout disasters” conservatives and the media have been screaming about.

It will be fascinating to see if Republican pols line up in support of P-CARE, which aside from the features/bugs I have been discussing, also violates Republican resistance to subsidizing health coverage for the uninsured at all. If they do, their ability to exploit discontent with change in health care may be significantly reduced, and it may also become impossible to avoid point-by-point comparisons with Obamacare that make “the alternative” look a lot less attractive.

Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.

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