It's Not That They Don't Know. It's That They Don't Care.

You don't have to expect every politician to be a serious policy wonk to believe that he or she ought to have a grasp of at least the basics of the key issues they debate. And if they don't have that grasp at the beginning of a debate, then they ought to by the end of it. If there's one thing we can say about the last year, it's that we all learned a lot about health-care policy. Or at least most of us did.

At the Atlanta Journal-Constitution, Jay Bookman discusses an interview the paper's editors did with Sen. Mitch McConnell, the leader of Senate Republicans, and Sen. Saxby Chambliss (h/t Steve Benen). It contains an extraordinary passage concerning banning exclusions for preexisting conditions and the individual mandate. As we all know, if you're going to forbid insurers from excluding people with preexisting conditions, you have to have a mechanism for keeping people from gaming the system by waiting until they get sick to get insurance. If you don't, costs enter a "death spiral," which is bad. That's what the mandate accomplishes -- it brings everyone in, so costs can be spread and no one can game the system in that fashion. Republicans have said all along they want to ban preexisting-condition exclusions. So how will they handle the free-rider problem?

So if the GOP plan is going to ensure that pre-existing conditions are covered, as Chambliss and McConnell suggested, how would they do it without individual mandates? What mechanism would they use?

Chambliss and McConnell had no answer. Literally.

After Chambliss fumbled an initial response, McConnell broke in with a long and familiar condemnation of the Democratic plan, including its failure to include tort reform. After a few minutes, I interrupted and brought him back to the question: OK, but how are the Republicans going to cover pre-existing conditions?

“The premiums are going up either way,” he said.

OK, I responded, a little stunned. That doesn’t explain how the Republicans intend to cover pre-existing conditions.

“The premiums are going up either way,” he repeated.

That was that. We moved on, and I still don’t have my answer.

There are a couple of possibilities here. It could be that McConnell and Chambliss simply don't understand this very fundamental piece of health-care reform policy. It could be, on the other hand, that they understand it, but they know that forbidding preexisting condition exclusions is just about the most popular piece of health-care reform, so they have to say they're for that, but they don't want to say they're for the far less popular individual mandate. It could also be that they understand the issue, but they know that their whole "Repeal and Replace" line is something they'll talk about for a while, until it eventually fades and everyone forgets about it (kind of like, say, George W. Bush's fervent support for a Patient's Bill of Rights during the 2000 campaign).

I think the latter is the most likely -- these guys aren't idiots (well, McConnell isn't, anyway), even if they're not particularly concerned with the details of policy. Because at the moment they aren't policy-makers. They don't have to worry about what can actually work in the real world, because none of what they're advocating will be tested in the real world. In order to repeal the Affordable Care Act, they'd have to not only take both houses of Congress back but then take back the White House too. Even if they did that, they'd take a good hard look at repeal and realize it isn't worth the political cost.

They surely don't like this reform, but they're realistic enough to know that the policy fight, at least over the essentials, is over. They'll get whatever campaign advantage they can out of it in terms of getting their base motivated this November, and maybe even in 2012. But I'll bet they know that repeal is never going to happen, so they can advocate pretty much whatever they want, without being concerned about looking like they have no clue what they're talking about.

-- Paul Waldman

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