After Obamacare

Our friend Tevi Troy, the author of outstanding books about the presidency, is also CEO of the American Health Policy Institute. During the George W. Bush administration, he served as deputy secretary of Health and Human Services.

Tevi, along with Lanhee Chen of the Hoover Institution, has written an op-ed on Obamacare for the Wall Street Journal (it’s behind the Journal’s pay wall). Their piece has two parts — a look back at the fight waged by the Republican Congress against Obamacare and a look forward at how to replace it.

The two parts of the op-ed are tied together by the fact that the Republican Congress didn’t just vote to repeal Obamacare — it offered plans to replace the legislation. Such plans include House Speaker Paul Ryan’s “A Better Way,” as well as plans from Sens. Richard Burr and Orrin Hatch and Rep. Fred Upton; Rep. Pete Sessions and Sen. Bill Cassidy; Rep. Tom Price, Sens. John McCain and David Perdue; Rep. Phil Roe and the Republican Study Committee; and Sen. Ben Sasse. In addition, conservative scholars and analysts have written “Improving Health and Health Care: An Agenda for Reform.”

Clearly, the GOP does not lack for plans.

What is the nature of these plans? According to Tevi and Chen, most of them “focus first on driving the cost of health care, expanding access to consumer-directed health arrangements like health-savings accounts, and replacing Obamacare exchange subsidies with a refundable tax credit or some other tax benefit to help lower-income Americans afford health insurance.”

Tevi and Chen recommend a four-step approach to the repeal and replace process:

First, states should be given greater latitude through executive action to pursue aggressive reforms to Medicaid.

Second, Republicans in Congress should move immediately to craft a budget resolution and pass it, thereby enabling the use of budget reconciliation legislation to repeal the law — as they did in 2015.

Third, they should implement transitional reforms that would prevent potential disruptions in coverage gained under [Obamacare], such as for those who benefit from subsidies for marketplace coverage.

Finally, a more extensive replacement bill can then follow.

I’m far from an expert in this field, but nonetheless offer two observations. First, other than people with “pre-existing conditions,” no one would be denied health insurance by virtue of an Obamacare repeal (with no replacement). Many would be denied free health insurance and many others would be denied subsidized health insurance, but that’s not the same thing as being denied health insurance.

Second, Obamacare replacement proposals shouldn’t be evaluated in terms of whether all those who have health insurance as a result of Obamacare will continue to have it. Obamacare has induced some who didn’t want to buy health insurance to purchase it anyway. If these consumers conclude in a post-Obamacare regime that they don’t want to keep paying for insurance, their lack of coverage shouldn’t be deemed a mark against that regime.

In addition, it is highly debatable whether everyone who got free or subsidized health insurance thanks to Obamacare ought to have received it. A Democratic Congress, without support from Republicans, picked the monetary cutoffs for the Medicaid expansion and the subsidies. By no means should these decisions be the benchmark for judging plans that might replace Obamacare.

Everything should be on the table (though I agree with Donald Trump that provisions regarding pre-existing conditions ought to be retained). Thanks to the tireless, and widely derided, efforts of Republican legislators to keep Obamacare on the political and policy agenda for the past six years, I trust that almost everything will be.