Health Care Play-Acting

I've written many times, by way of explaining congressional Republicans' actions on the issue of health care, that it just isn't something that conservatives as a group care very much about. They have other interests, like taxes and the military, that they'd much rather spend their time on. This may strike some as unfair, but I think it's pretty clear from everything that's happened over the last couple of decades that it's true. There are a few conservative health wonks, but not nearly as many as there are on the liberal side. I can't think of any conservative journalists who are deeply conversant with the policy challenges and details of the health care system, while on the liberal side we have a number of such people, like Ezra Klein and Jonathan Cohn. Liberals have organizations dedicated to reforming the health system and achieving universal coverage; conservatives have organizations dedicated to stopping liberals from reforming the health system and achieving universal coverage. Other than an eternal desire to limit the ability of patients to sue for malpractice (which is as much about hamstringing trial lawyers, who donate a lot of money to Democrats, as it is about improving health care), Republicans only propose anything intended to improve the health care system when political events make it impossible for them to remain silent.

Which is why it's reasonable to be highly skeptical whenever congressional Republicans start talking about what they'd like to do on health care. That's the proper spirit to take the latest news on how conservatives are positioning themselves:

Senate Republicans are echoing the House GOP’s shift in favor of some of the more popular “Obamacare” provisions, a sign that the party is uniting behind the strategy ahead of the election.

With a Supreme Court decision looming next month, House Republicans are privately weighing a plan to reinstate three popular elements of the law if it’s struck down — guaranteeing coverage regardless of pre-existing conditions, allowing young adults up to 26 years old to remain on a parent’s insurance policy, and closing the Medicare prescription drug coverage gap known as the “doughnut hole.”

Whether coverage of pre-existing conditions is economically viable for insurers without an individual mandate is a dubious proposition, but practical realities are taking a back seat to election year imperatives. It’s not a hard sell to voters: you can have all the popular provisions of health care reform without the unpopular ones.

Politically, this makes perfect sense. Keep in mind that should the Supreme Court strike down the Affordable Care Act, everything you don't like about the health care system will immediately be laid at the foot of Republicans. Democrats will say, completely accurately and probably persuasively, "You're upset that you can't get coverage? You're upset that your premiums went up? You're upset that your kids are uninsured? We fixed that, but Republicans sued and got their friends on the Supreme Court to undo it, so blame them." So in the short term at least, Republicans have to look like they care. Critically, two of the three things they're proposing to keep from the ACA—young adults being allowed on their parents' insurance and the closure of the doughnut hole—have already taken effect. Which means if the law is overturned in its entirety, a benefit people now enjoy will be taken away from them, which is much worse than not getting a benefit you haven't yet gotten. The third element, on pre-existing conditions, is the most important thing the ACA did, giving Americans security in their coverage where they currently have none. So saying you're for that is a political no-brainer.

But saying that they want to eliminate exclusions for pre-existing conditions without any kind of plan to get to universal coverage just shows how unserious Republicans are about this. As anyone who knows the first thing about the health care system will tell you, mandating that insurers take all comers without regard to pre-existing conditions, and charge everyone roughly the same rate—in other words, not saying, "We'll insure you even though you had cancer, but your premiums will be $20,000 a month" — will destroy the insurance industry if it's not paired with something like the individual mandate that brings everyone into the risk pool. If you were allowed to wait until you're on the way to the hospital to apply for health insurance, and they had to take you, insurance companies would go out of business.

You can be sure the insurance companies' lobbyists have explained this to their Republican friends. But those legislators don't seem particularly concerned, because they're not really all that serious about doing anything on health care. If the Supreme Court overturns the ACA, their job will be done, since Barack Obama's signature domestic policy accomplishment will have been undone. They might put out something that looks like a plan to do something on health care, but as soon as the political pressure wanes, they'll move on to the issues they're more interested in.

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