National Review Online
Friday, January 06, 2017
On health care, congressional Republicans should listen
to Donald Trump. The president-elect may not be chock-full of ideas about
health-care policy, but he has the right political instincts. He has said that
Obamacare should be replaced, that its beneficiaries should not simply be
stripped of coverage, and that people with pre-existing conditions should be
protected. It is possible and desirable to devise legislation that meets these
objectives. Trump has also warned congressional Republicans to be careful — and
he is right about that, too, because their current course does not look likely
to accomplish the repeal of Obamacare or its replacement by something better.
Senate Republicans want to pass a bill that repeals the
taxes and spending in Obamacare, but not its regulations. That’s because they
think that they can use a legislative process to avoid Democratic filibusters
only if they leave the regulations alone. They think that this partial repeal of
Obamacare will set the stage for later legislation that repeals the rest of the
law and creates a replacement.
This seems highly unlikely. Leaving Obamacare’s
regulations in place while getting rid of its individual mandate — a tax
measure, which Republicans would eliminate in their first bill — would further
destabilize health-insurance markets. No one would cheer the Republicans for
producing that outcome: not conservatives, who would know that Republican
boasts of having repealed the law were false; not the many voters of all kinds
who would see their insurance disappear or grow still more expensive; not the
Democrats, who would be happy to blame Republicans for this mistake and
everything else that goes wrong with health care afterward.
A better course would begin with the recognition that
Obamacare’s regulations are the heart of what is wrong with it. The federal
government had been subsidizing the purchase of health insurance for scores of
millions of people for decades before Obamacare came along, in ways that
created some serious problems. But it was not until Obamacare that the federal
government became the chief regulator of health insurance. President Obama and
his allies believed that the solution to the problems with health insurance —
the large number of people who lacked it, its rising price — was to impose
rationality on it from Washington, D.C. It is these regulations that are
responsible for most of the complaints about Obamacare: the plans that have had
to be discontinued, the rising premiums, the difficulty insurers have had in
making a viable business on the exchanges.
Obamacare also creates tax credits that people who don’t
have health insurance from their employers can use to buy coverage. There is
nothing wrong in principle with allowing people who get coverage themselves to
have tax breaks equivalent to the ones that benefit people who have employer
coverage: Conservatives have argued for that approach for years. But
Obamacare’s credits are complicated, are structured in a way that discourages
work, and can be used only for the purchase of insurance policies that comply
with Obamacare’s regulations.
The core of a conservative replacement of Obamacare — a
replacement that is simultaneously a repeal — would be the end of the federal
government’s role as chief regulator of health insurance and the restoration of
the states to that position. Simplify the tax credits, pare them back if
possible, and allow them to be used for any insurance policy that meets these
two conditions: The policy meets the approval of state regulators, and people
who maintain coverage can continue to buy such coverage at the same price if
they get sick. People would have much more freedom to buy the coverage that
meets their specifications rather than those of Washington regulators; they
would have the means to buy basic coverage; and they would have the incentive
to do it as well (since maintaining coverage would protect them in the event
they got sick).
The mandate to buy insurance — a mandate that came into
existence in order to counter the side effects of Obamacare’s onerous
regulations — should simultaneously be abolished. And most people on Medicaid
should be given the option to cash out their benefits and buy insurance on the
regular, private market.
Too many congressional Republicans think that
conservatives will take a quick but phony win on health care. We disagree. A
real win is worth the time and effort.
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