The ACP Advocate Blog
by Bob Doherty
Thursday, January 23, 2014
The Confusing Conservative Critique of Obamacare
Conservatives could muster a clear-thinking critique of Obamacare if they wished, and maybe even put forward a genuine alternative. Unfortunately, though, many of the conservative attacks on Obamacare don’t make much sense, when evaluated against conservative’s own heretofore views, not against liberal concepts of good policy.
Let’s breakdown conservatives’ confusing arguments against Obamacare that don’t jibe with their previous positions:
1. Conservatives used to be for high deductible plans, until they were against them, when it comes to Obamacare, that is. Bloomberg News points out that Republicans in the early 1990s advocated for high deductible plans as an alternative to the more generous benefits proposed by President Clinton:
“As Democrats pushed for universal health care during the Clinton years, Republicans argued that consumers should pay a greater share of their medical bills. In 1996 the GOP-controlled Congress passed legislation allowing some people to pair high-deductible plans—which barely existed—with tax-free health savings accounts. That meant that small business owners and their employees, as well as others with limited insurance options, could put away pretax earnings to pay for routine care and buy cheap insurance to cover catastrophes. In 2003 Congress, still under GOP control, passed legislation making health accounts more widely available.”
Today, Republicans are in a lather about Obamacare’s high deductible plans, exposing what policy wonk Ezra Klein deems “their hypocrisy” over Obamacare (his words, not mine—I think inconsistency is a fairer description). Aaron Carroll, a professor of pediatrics at the Indiana School of Medicine, opines in Bloomberg that conservatives newfound dislike of high deductible plans brings them to the right (correct) position:
“The revelation that many plans in the Patient Protection and Affordable Care Act’s health insurance exchanges have high deductibles, has put many of the law’s conservative opponents into a corner: Once in favor of high deductibles, these critics of Obamacare are suddenly worried about the risk to consumers. The data show why their new position makes more sense.”
2. Conservatives used to be in favor of moving people out of employer-based coverage but now bemoan every employer who drops coverage because of Obamacare. Typical is an anti-Obamacare screed from the Republican Senate Policy Committee, warning that people “relying on employers to cover employees’ spouses on the company health plan may find the health care law isn’t ‘working fine’ for them. The law’s mandates and fees are driving up health care costs and making it harder for employers to continue offering health insurance to workers’ families. Some employers have even stopped offering spousal coverage altogether.” Avik Roy, a conservative physician commentator and former Romney advisor, has predicted that Obamacare will result in employers “cancelling” policies for 80 million employees (which, by the way, has been disproven by independent fact-checkers—his estimate is way too high, and the policies aren’t actually being cancelled, just changed to meet Obamacare’s requirements, such as the requirement that young adults be eligible for coverage under their parents’ plans).
But even if it were true that some employers eventually will decide no longer to provide health insurance in favor of allowing their employees to buy individual (and subsidized coverage) from the competing health plan offered through Obamacare’s exchanges, delinking health insurance from employment used to be what conservatives favored (and some still do). For example, the libertarian Cato Institute supports elimination of the tax deductibility for employer-sponsored insurance—a far more radical and disruptive approach to ending employer-based insurance than any drop in employer-based coverage from Obamacare:
“In any case, with the removal of the subsidy for health care above catastrophic coverage, the incentive to obtain so much insurance would diminish. Thus, many people would reduce coverage to that level. Insurance companies could help individuals with catastrophic risk management—their traditional function. Firms could get out of the business of managing, rationing, and buying health care. We would delink insurance from employment, ending the portability problem and dramatically reducing the brouhaha over pre-existing conditions. Individuals would have better incentives and more control. More broadly, we need to move away from third-party payment and toward two-party transactions in health care.”
3. Conservatives invented the idea that individuals should be required to buy health insurance but now vociferously oppose Obamacare’s individual mandate. Forbes magazine recounts conservatives’ “torturous” shift on the individual mandate, from originally favoring it as a market-based, personal responsibility alternative to compulsory government-mandated coverage (single payer) or employer-mandated coverage, to now decrying it as socialism:
“. . . Some conservatives, seeking a more market-oriented path to universal coverage, began endorsing an individual mandate over an employer mandate. An individual mandate would address the ‘free rider’ problem caused by EMTALA, by requiring people to buy their own insurance. In addition, moving to a more individual-based system from the employer-based one would significantly increase the efficiency of the health-insurance market.
With these considerations in mind, in 1989, Stuart Butler of the Heritage Foundation proposed a plan he called ‘Assuring Affordable Health Care for All Americans.’ Stuart’s plan included a provision to ‘mandate all households to obtain adequate insurance,’ which he framed explicitly as a way to address the ‘free rider’ problem and employer mandates.”
To be fair, there is plenty of inconsistency among liberals, and people often change their minds, for good or at least justifiable reasons in their own minds. But the fact is that until Obamacare, the conservative alternative to government-run health insurance was to provide tax incentives for people to enroll in high deductible plans, to delink coverage from employment, and to require that people to buy coverage. Yet they oppose these elements when associated with Obamacare.
This is a problem, because this country needs to have a spirited debate about today’s conservative alternative to Obamacare, one that would limit government and promote free markets yet still expand access to millions of uninsured. But conservatives need to first figure out what they are for, not just what they are against, which apparently is anything having to do with Obamacare, even if similar to the things they used to be for. Do they still favor high deductible plans? Do they still want to delink coverage from employment? If they no longer support an individual insurance mandate, what alternative do they have in mind to make sure that risk is spread among the young and healthy and the old and sick? We need to know.
Finally, before readers of this blog accuse me of only going after the conservative response to Obamacare, stay tuned. My next post will be about liberals’ blind-eyes to the unintended adverse consequences of Obamacare.
Today’s questions: Do you agree that conservative critiques of Obamacare are confusing and inconsistent with their past views? And if so, is this a good or bad thing?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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