President Obama has lost almost all credibility defending the Affordable Care Act: Hiccup after hiccup have marred its implementation, its taxes and spending will hurt economic growth, and it will raise consumer health costs. But Obama may have had a point when he charged last week that Republicans are talking about repealing the law without saying what should replace it.
Republicans would be wise to debunk the president’s claim head on. Recently, we have focused almost all of our energy and effort on the question of who is “purer” or “more conservative” in the fight to repeal Obamacare. Let’s just agree that every Republican wants to repeal Obamacare. Now it’s time to coherently articulate a vision for what should replace the fundamentally flawed health-care law. A failure to do so could have electoral consequences in 2014 and beyond.
Republicans aren’t lacking for ideas about what to replace Obamacare with. Scholars at almost every right-leaning think tank have presented plans for a patient-centered, market-based health care reform. Representative Paul Ryan of Wisconsin wrote legislation in 2009 known as the Patients’ Choice Act that would have enhanced the portability and affordability of private health insurance, while giving states greater flexibility and authority to innovate in the Medicaid program. Many of Ryan’s ideas remain salient in a post-Obamacare world.
And during last year’s presidential campaign, Mitt Romney’s first policy speech was a comprehensive set of ideas designed to replace Obamacare with reforms that would bring down the cost of health care, reduce the ranks of the uninsured and help those with pre-existing conditions get access to coverage.
Despite these ideas, Republicans have avoided the discussion of what should replace Obamacare because there are divisions within the party over the best policy approach. There is broad agreement that cost remains the primary problem, so policies that speak to this concern — enabling the interstate purchase of health insurance, reforming the medical liability system, and bringing greater transparency to the pricing of medical procedures — are broadly popular. Republicans also agree on changing the existing tax treatment of health care, which discriminates against those who obtain health insurance on their own, rather than through employers.
Look beyond these issues, however, and you’ll find substantial disagreements. Some conservatives, for example, reject the very notion that expanding access to health insurance is a priority, while others believe that efforts to cover the uninsured are both political and policy imperatives. A number of conservatives, myself included, have argued for limited federal regulatory intervention, coupled with federal funding for state high-risk pools, to help those with pre-existing medical conditions get access to health insurance. Others would like efforts to help those with pre-existing conditions focused entirely at the state level.
There is also a wonkier, but highly significant, debate over what kind of tax preference should replace the existing treatment of health insurance expenses. President George W. Bush proposed that it be replaced with a standard deduction that every American could use to buy health insurance. Sen. John McCain, R-Ariz., proposed during the 2008 presidential campaign that every American receive a refundable tax credit to defray the cost of coverage. And Romney favored equalizing the tax treatment, in part, by extending a deduction to those who purchased insurance on their own. The ideas may sound similar, but they have different deficit implications, are targeted at different groups, and would cover different numbers of Americans.
There’s also disagreement about the scope of reform. Some conservatives would prefer a more incremental approach, where reforms are enacted piecemeal, while others have argued for a more comprehensive approach.
These are substantial policy debates, and they suggest the challenge of getting a majority of Republicans on board with a single plan to replace Obamacare. But these are debates worth having, and it’s a result worth achieving. Republican policymakers must work toward consensus, because while repealing Obamacare is important, replacing it with policies that will actually improve our health-care system will be the bigger accomplishment.
Rather than debating the merits of shutting down the federal government over funding for Obamacare, Republicans should be able to respond to President Obama’s outrageous claim that our party is unified behind “making sure that 30 million people don’t have health care” with more than just a call to defund his signature health-care law. We should be able to present the American people with common sense ideas and positive alternatives that address Obamacare’s fundamental deficiencies.
Lanhee Chen is a Bloomberg View columnist and a research fellow at the Hoover Institution at Stanford University. He was the policy director of Mitt Romney’s 2012 presidential campaign.