It's about health insurance, not Obamacare

Forget 2010. The baseline is now.
April 10, 2017
hospital corridor

Many liberals favor single-payer health insurance. It’s the most direct path to expanding coverage, and by setting prices centrally it would bring down costs. If the starting point is the premise that basic health care is a right, this is the most straightforward approach.

Many conservatives would prefer to guarantee coverage for catastrophic health problems only, leaving day-to-day care up to a free market of sellers and buyers. Here the priority is a less regulated system and the innovation it can foster. It’s a straightforward approach if the starting point is that health care is a consumer good, not a right.

Each of these is a coherent public policy vision, with clear tradeoffs. Neither has much to do with Obamacare—or with the recent GOP effort to roll it back.

The 2010 law is not straightforward because it’s not a discrete entity created to reflect anyone’s vision, conservative or liberal. It’s a set of interventions in the existing system, calibrated to balance interests and get the bill passed. Obamacare represents a middle way between left and right—but a far more complex one than either side would ever create from scratch.

When GOP leaders tried to repeal Obamacare in March, their bill didn’t capture a conservative vision for health care any more than Obamacare captured a liberal one. Its purpose was political: having promised repeal, Republicans wanted to be able to say they had delivered.

Unfortunately for the leadership, the GOP’s own members read the bill. Hard-line conservatives got the credit for blocking it, rejecting the bill for what it didn’t do (scrap the existing system). But there were also moderate Repub­licans who rejected it for what it did do: take coverage away from millions of Americans. The latter group’s stand shows they appreciate the stakes here. (So do the GOP governors defending Medicaid.) Obama­care is not a distinct item to embrace or reject; it’s integrated into the wider system people rely on.

Conservatives haven’t given up on repealing Obamacare, and even if they do, the Trump administration may refuse to administer the law’s provisions effectively. Still, by rejecting their party’s bill, GOP moderates have established something important: the nation can’t keep debating a question formulated around the former president’s legacy. The issue isn’t Obamacare; it’s health insurance. The baseline is now, not 2010.

Lawmakers who accept this could work on fixing the individual insurance market, where Obamacare has improved things but also fallen short of its goals. Insurers are abandoning markets where they don’t make money. Higher subsidies for buying coverage would help—and stronger penalties for not buying it. So would direct protections for insurers.

Some such steps would mean doubling down on signature Obamacare provisions. But similar provisions exist in any plausible plan that builds on the existing system. It’s not yet clear whether many Republican officials are ready to set aside the politics of opposing Obamacare. If they do, maybe lawmakers can work together to keep building.

A version of this article appears in the April 26 print edition under the title “Health care after Obama.”