This column is a collaboration between KHN and
The New Republic
It will force a lot of people to pay higher premiums. It will lavish subsidies on the private insurance industry. It will put life-and-death decisions in the hands of bureaucrats. And it will add hundreds of billions of dollars to the federal debt.
No, I am not talking about the health care reform law. I'm talking about the Republican proposals to repeal it.
Since even before the Patient Protection and Affordable Care Act became law, Republicans have been vowing to get rid of it and to pass their own reforms instead. It makes a lot of sense politically. The voters are angry at Washington. The voters are also worried about their access to health care. By promising to "repeal and replace," as the slogan goes, Republicans sound like they're giving the voters exactly what they want.
But would the Republican plan make health care better -- or worse? Consider, for starters, that the health overhaul will, starting in 2014, expand Medicaid and make subsidies available to lower- and middle-income Americans who buy private insurance. Multiple estimates, including those from the Congressional Budget Office, suggest that that an additional 30 million people will get insurance because of these changes.
The Republicans say they have their own mechanisms for expanding insurance coverage. On the official website for congressional Republicans, party leaders propose such measures as allowing the purchase of coverage across state lines and creating special insurance plans for people with pre-existing conditions. But studies have repeatedly shown that proposals like these would, at best, bring coverage to just a few million Americans. So if the Republicans succeed in taking the recently enacted reforms off the books, that means they are taking insurance away from a whole lot of people.
Of course, advocates of repeal have made pretty clear that expanding coverage isn't that big a deal to them. Their primary concern, they say, is with making health care cheaper for people who already have it. But it's hard to see how getting rid of health care reform would accomplish that goal, either. The new law includes a bunch of measures designed to reduce the overall cost of care -- first by a little bit, and then by a lot. It would also establish an insurance exchange that gives individuals and small businesses access to the kind of group policies large employers now have -- complete with those subsidies, which will offset some or most of the cost for people who would otherwise struggle to pay the premiums on their own.
Although the effect of these changes on individual premiums will vary a lot from person to person, the CBO concluded that, once you account for the subsidies, reform will mean lower average premiums for people with private insurance. Repeal reform and these people are stuck paying more (unless Republicans are willing to let benefits get a lot more skimpy). The official projections also suggest that, ten years from now, government spending on health care will be lower than it might otherwise be. Repeal reform and the deficits go back up -- by more than $100 billion over ten years. And while the nation as a whole will pay slightly more for health care over the next ten years, the rate of growth -- which is the figure we care about most -- will be lower. Take away reform and, according to the projections, health care costs will rise at a higher rate.
Again, the Republicans have their own ideas about reducing costs. A few of them have merit. (In principle, for example, malpractice reform makes sense, if done right.) But most experts believe the mainstream Republican proposals won't significantly bend the cost curve. Rep. Paul Ryan, R-Wis., has famously put forward a more radical plan, to transform Medicare into a voucher system. But the Republican leadership had refused to back up that idea, perhaps because it would control costs only by dramatically reducing the insurance coverage that seniors get.
But wait a minute -- wouldn't that all be worthwhile in order to get the government out of medical care? Given all the stories of "socialized medicine" and "death panels," it might seem that way. But those things exist only in the imagination of dishonest and hysterical critics. On the other hand, the health overhaul does include a bunch of consumer protections, many of which are already taking effect. There are or will be standard benefits that all insurers will have to cover, requirements for more disclosure so that consumers will be able to shop intelligently and find the best plans, and guarantees of the right to appeal treatment denials. If you take away health reform, all of those protections go away -- and consumers will be more vulnerable to the whims of faceless insurance company bureaucrats, whose goal may be to maximize profits rather than public health.
The health law is far from perfect. Critics on the left and right can find plenty to criticize legitimately. But reform also promises a lot of benefits -- to individuals and to the country as a whole. Can Republicans make the case that Americans would be better off without these benefits? It's about time somebody forced them to answer that question.
Jonathan Cohn is a senior editor at
The New Republic