For more than three years, Republicans have engaged each other in a heated debate over whether the proper response to the passage of the Affordable Care Act is to repeal it and replace it with something else, or to just repeal it and return to the pre-Obamacare status quo.
In effect, their actual position is the latter. They've voted to repeal the law over and over again, but have never reached a consensus on a single plan to replace it. And at times during the long lead-up to Obamacare's big launch, that failure has been a liability for them. It's damaged their credibility as healthcare reform critics with the press and the public alike. The old system sucked! Why should we go back to it?
Given how troubled the Obamacare rollout has been, you might think that Republicans are kicking themselves particularly hard right now for not settling on a "GOP healthcare plan." What better time to argue for repeal than under circumstances like these?
But you'd be wrong. If anything, they're incredibly relieved. Because a "replace" plan would neutralize what has proved to be one of their best, and relatedly most disingenuous, lines of attack against the law since it passed in 2010.
We know the outrage Republicans are expressing on behalf of people receiving cancellation notices from their individual market insurance plans is phony because it's obviously phony. They don't have any particular interest in ameliorating this phenomenon short of repealing or destroying the rest of the law. And its effectiveness as a talking point hinges on never acknowledging that Obamacare has helped anybody.
But the most revealing tell, identified here by the New Republic's Jonathan Cohn, is that all of the healthcare reform plans Republicans support would disrupt the insurance market much more dramatically than the Affordable Care Act does. Republicans can't achieve consensus on a plan to replace Obamacare, but they all basically agree that very few people should be allowed to keep the insurance plans they have right now.
Jonathan explains how almost all GOP plans would kick millions of people off of Medicaid, and inflict adverse selection on the employer-sponsored insurance market by creating a huge incentive for healthy workers to abandon their group plans for individual ones. The ensuing death spiral would result in more cancellation notices and "rate shock" than we're seeing now by an order of magnitude, but without the safety net of the Affordable Care Act's exchanges to catch people.
The National Review's Ramesh Ponnuru's solution to this problem is to rip the band-aid off slowly. Whereas Obamacare creates an immediate disruption for a relatively small group of individual policyholders, Republicans should create a slow, steady disruption for tens of millions more.
Other smart conservatives -- which is to say, policy wonks without much cachet on Capitol Hill -- would replace all insurance with subsidized catastrophic coverage and tax-preferred health savings accounts. Nobody with private insurance or Medicaid would get to keep what they have, no matter how much they like it.
I'd add another. Nearly all Republicans support eliminating traditional Medicare for future retirees, and replacing it with a plan that looks (ironically) a lot like Obamacare. The sales pitch version of the plan is that Republicans want to keep the promise the country made to current retirees and people nearing retirement, but radically overhaul it for the young and middle-aged. Over time, single-payer Medicare would be phased out.
But as nearly every healthcare expert will tell you, the phase-out would be massively disruptive. As the program's beneficiaries aged and dwindled in number, it would become unsustainable very quickly. Without scale, the government would lose its purchasing power, and would either have to fork over tons of money to motivate providers to care for beneficiaries -- a bailout -- or watch providers abandon the program en masse, leaving the country's oldest, sickest people little choice but to enter the private insurance market.
Republicans are treating Obama's "if you like your plan you can keep it" pitch as the noble lie from which all of the apocalyptic consequences of the Affordable Care Act will ultimately spring. The original swindle. But the focus-grouped deception they hope to perpetrate against seniors is far more egregious.
If a consensus GOP plan existed today, Republicans would have to square their outpouring of sympathy for beleaguered young policyholders with the radical intent of their own vision. I imagine they -- like Obama! -- wouldn't be forthright about the consequences. The truth is, that plan would fail on the floor of the House either way. Precisely because it's so radical, I strongly doubt there will ever be a political constituency for it. Even if Republicans someday control the government again. (Remember the last time they controlled the government and ruptured the healthcare system? Me neither.) But if someday they do, and charge ahead with a plan that contains elements like these, the consequences and the political fallout will make the great cancellation row of 2013 look like a website glitch.