GOP Settled on Repeal, But Still No Replacement

Two years after committing to full repeal of the law now known as Obamacare, Republicans face the possibility that the Supreme Court may strike it down before they get a chance. Yet they still lack a settled plan for replacing Obamacare. This is a major point of criticism for the law's boosters.

The GOP's reluctance to spell out its plans for the health insurance market has something to do with the political downside involved. According to Sen. Tom Coburn of Oklahoma, Republican leadership “would much rather get hammered for not having a replacement plan than get hammered for the specific details” of said plan.

Risk aversion, however, is far from the whole story. After all, almost every Republican voted for similarly sweeping reforms to Medicare and Medicaid proposed by Budget Committee chairman Paul Ryan. Changes to those programs, which constitute the majority of the federal government’s involvement in health care, are at least as dangerous politically as a replacement plan for Obamacare would be.

There are two other major reasons the GOP isn’t motivated to commit to a specific replacement. The first is that Republicans do not prioritize achieving universal access to insurance the way liberal health care advocates do. Where Obamacare’s proponents believed that increasing access was a precondition for lowering costs, Republicans tend to believe the reverse: that lowering health care prices by reforming existing inefficiencies in the health care market will yield greater access. That logic that lends itself to a more incremental approach than a one-shot bill.

For example, Rep. Jim Jordan of Ohio, the chairman of the Republican Study Committee (a group of conservative legislators), believes that the GOP “should spell out exactly what we’re for” with a detailed plan, and continue making the argument that reforms that empower individuals to make health care choices will lead to lower prices.

Nevertheless, Jordan says he’s “not wed to a single bill,” and thinks it was “obviously a mistake” for the Democrats to pursue all their reforms in one big bill. “Maybe it makes more sense to do it in smaller chunks.”

In an interview with the Washington Examiner, Sen. Jim DeMint argued that Republicans “don’t believe in one alternative to replace [Obamacare]. I mean we know there are things that we need to do to facilitate the ultimate goal which is for individuals to own their own policies, policies that they can keep from job to job and until the end of retirement.”

Senate Minority Leader Mitch McConnell echoed DeMint’s comments in an interview with conservative columnist Ramesh Ponnuru, stating that “We would want to more modestly approach this with more incremental fixes.... Not a massive Republican alternative.”

What would those incremental fixes look like? Rep. Tom Price, a doctor from Georgia who has been promoting his own comprehensive alternative to Obamacare since 2009, suggests three fixes in an interview with RealClearPolicy:

1) A system of individual tax credits for purchasing health insurance that would mitigate the inefficiencies caused by the tax preference for employer-provided health insurance.

2) State-level pooling mechanisms for covering people with pre-existing conditions.

3) Lawsuit abuse reforms.

Each such reforms, Price believes, would lower health care prices. The lower prices would increase insurance coverage.

Republicans believe their reforms would do no less to cover the uninsured than Obamacare, with its individual mandate and guaranteed issues provisions, would. “Our plan would cover more individuals in the real world than theirs,” Price says, after noting that Obamacare would leave millions still uninsured after its implementation.

“The reason [the uninsured] can’t get access is because it costs 50 percent more than it should,” Coburn says, arguing that prices are driven up by a lack of a functioning market. “Until you address those problems, I don’t care what system you put in, you’re not going to address” the problem of the uninsured.

“If you lowered health care costs by a third in this country, what would happen? What would happen to access and affordability?" Coburn asks. Answer: "It’d become affordable.... It’s not hard to put together a package that will work. It’s hard to develop the political will ahead of an election.”

The president’s approach -- designing a system that subsidizes families to purchase insurance from exchanges, and mandates that individuals buy coverage -- necessitates a comprehensive approach. Conversely, because the Republican vision could be achieved in steps, there isn’t a political motivation to do it all at once.

Not that all are satisfied with that reality. “I don’t think we have the time to do incremental reform,” Coburn says, adding that he doesn’t know why Republicans haven’t put an alternative to Obamacare up for a vote. “You oughta put out a comprehensive plan.”

ANOTHER KEY FACTOR behind the Republicans' hesitation to vote on a bill is the fact that GOP members are far more focused on the budget and debt than they are on problems in the health care market. They understand many health care issues through that budgetary prism.

Thanks to Tea Party pressure and the effort of Rep. Paul Ryan, Republicans have already tested their willingness to take risky votes, with Ryan’s Medicare and Medicaid plans. They think they have little political capital left over for a major overhaul of health insurance regulations.

Price explains that the “budgetary challenge is immediate” in the case of Medicare and Medicaid, and less obvious in the case of the rest of the health care market.

“Budgetary problems are easily explicable, because it comes down to a number on a line,” Price suggests. The “nuances and intricacies of the health care system are more complicated than a line in the budget.” He thinks that winning over other Republicans on the necessity of an alternative to Obamacare will be an “education process.”

On the fiscal problems posed by Medicare and Medicaid, Jordan says, “there’s been a longer education process for members. Probably, they need to learn a little more in terms of Paul Ryan’s [replacement proposal] or Rep. Tom Price’s proposal.”

Indeed, Ryan’s fiscal reform package was itself an education process: it failed twice before being embraced, in updated versions, by the whole House GOP. This year’s budget passed the House without including Ryan’s vision for replacing Obamacare.

WITH THE POSSIBILITY that the Supreme Court could strike down the entirety of the new health care law in just a few months, Democrats' criticisms of Republicans' lack of an alternative carries extra weight. Yet the GOP already has its work cut out defending the votes to change Medicare to a premium support model and block grant Medicaid to the states.

The votes in Congress on health care issues are likely done for the year, but that doesn't mean the issue will go away. Far from it. The GOP presidential nominee will have no choice but to outline a comprehensive plan, as John McCain did in 2008. Even though the likely nominee, Mitt Romney, signed a law in Massachusetts that many think of as the model for Obamacare, his plan is likely to feature most of the provisions that congressional Republicans favor.