At the highest level of abstraction, the idea of the Affordable Care Act is that over time Americans should be transitioned out of a blend of employer-provided insurance and lack of insurance and into a system of regulated, subsidized, individual plans. The model is Switzerland. And in an informative Reuters piece, Douglas Holtz-Eakin and Avik Roy—two of the most important conservative health policy thinkers around—propose that Republicans embrace a system whose goal is to transition Americans into a system of regulated, subsidized, individual plans modeled on the Switzerland approach.
In other words, they want Republicans to surrender.
No repeal of Obamacare, no denouncing the individual mandate as unconstitutional, no insistence that the uninsured can just go to the emergency room. Surrender.
Not unconditional surrender, of course. Roy and Holtz-Eakin are conservatives who want to reduce spending, so they favor making the subsidies less generous. In order to make less generous subsidies viable, they want to loosen the regulations to make the insurance plans stingier. They want to gradually-but-steadily raise the eligibility age for Medicare, so that over time a larger-and-larger share of the elderly population will be covered by Obamacare rather than Medicare. Last, and by no means least, they want to transition low-income Americans out of Medicaid and into the Obamacare exchanges. If you did all that stuff, then you wouldn’t need as much tax revenue to finance Obamacare.
So don’t get me wrong, these are substantial changes they’re proposing. But don’t buy their rhetoric either, this isn’t an alternative to Obamacare. It’s a negotiated surrender. In fact, it’s exactly the kind of outcome the White House was hoping for when they launched this process back in 2009. They really wanted a bipartisan bill that a dozen or more Senate Republicans would vote for. It would have made Obama look better, would have given vulnerable Democrats political cover, and it would have sped the process and let other items get on the legislative agenda. If at the time Republicans had organized around concrete asks in exchange for guaranteed votes, they could have easily gotten them. Key players like Max Baucus and Joe Lieberman and the then-large Blue Dog Caucus that held the median position in the House of Representatives were not adverse to this kind of thinking. America ended up with a more left-wing bill because Republicans instead adopted a tactical posture of root-and-branch opposition.
Now the GOP can’t just turn around and get the deal they could have had four years ago. Four years ago these asks would be on the table in exchange for voting for the bill. Now that the bill has already become law, if Republicans want to accomplish some of these things they need to put concessions on the table. Raising the Medicare eligibility age in exchange for introducing a reasonably strong public option, for example, should have some appeal. And it’s well-known that the Obama administration is eager to cut spending in various ways in exchange for higher taxes.