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February 10, 2014 12:05 PM Next Cookie on the “Repeal and Replace” Platter

By Ed Kilgore

I’ve been very interested to see whether the Coburn-Burr-Hatch PCARE proposal, which has been getting high hosannas from conservative think-tankers and gabbers, would gain enough purchase among Republican pols to emerge as the main “replacement for Obamacare” idea, despite its relatively—ahem—liberal treatment of those people and its sizable cut in the deduction for employer-based coverage.

As of today, though, PCARE isn’t even the top cookie on the platter: that would be a new proposal that The Weekly Standard is backing, from its affiliated Project2017, that follows a path similar to PCARE but with less redistribution of federal health care subsidies.

Unlike PCARE’s means-tested tax credit for purchasing health insurance in the individual marketplace, the Project2017 plan would offer a flat, universal credit pegged at a lower amount. Even more clearly than PCARE, this new proposal envisions a health care system where everybody (ultimately including Medicare beneficiaries) would have a Health Savings Account to cover routine care and a bare-bones catastrophic coverage plan that would provide a cap (albeit a very, very high one) on out-of-pocket expenses. As with previous GOP plans, this one deals with pre-existing condition exclusions via a combination of limited protections for people with continuous coverage and by throwing some money at state-run “high-risk pool” ghettos—while, simultaneously, inviting new innovations in discrimination by interstate insurance sales, which for all the talk of “competition” would probably just lead insurers to co-locate in the friendliest possible states. And like previous GOP proposals, Project2017’s aggressively opposes preventive-care-oriented minimum benefit mandates on grounds that the market knows best.

Above all, the new proposal makes plain the conservative assumption that the main reason for health care cost inflation is over-utilization of medical services, not price-gouging and cherry-picking by providers and insurers. Thus the path to less costly care is less care, achieved by making the patients who are always touted as the center of the conservative health policy universe bear much more of the cost of non-catastrophic expenses than under Obamacare or the status quo ante.

It’s unclear at this point whether the Project2017 represents a muddling of conservative positions on Obamacare “replacement,” or a politically driven refinement of PCARE (refined in that it looks more attractive—at least when segregated from similar conservative “visions” for Medicare—to upper-middle-class folk and also “young invincibles” who could transfer their universal tax credit into HSA cash). It’s interesting that National Review’s Yuval Levin, who has both praised PCARE and criticized it as politically risky, is on the four-member Project2017’s board of directors (chaired by Bill Kristol).

If I had to guess right now, I’d figure both PCARE and the Project2017 plan will serve as evidence of conservative willingness to deal with the manifest problems of the pre-Obamacare health care system, without commanding any particular allegiance from Republican pols. Having demonstrated their “seriousness,” they can happily return to Obamacare demagoguery and wave vaguely at this or that “plan” as illustrating the glorious future of health reform once the GOP seizes total power in Washington. It would be more convincing had Republicans offered such plans as alternatives to the Affordable Care Act while they were fighting it back in 2009 and 2010, but better late than never, I guess.

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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