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Posted at 2:17 PM ET, 03/ 2/2011

What is the health-care reform that Republicans actually want?

By Ezra Klein


By now, you probably know the basics of Wyden-Brown: If a state comes forward with a proposal to cover as many people, at as affordable a cost, with as comprehensive insurance, without increasing the deficit, it can ignore the Affordable Care Act and go its own way. Put simply, the administration is calling and raising: If the Affordable Care Act is so bad, then show us that you can do better.

The problem is, conservatives can't do any better -- at least not under these rules. This is an important point, so it's worth dwelling on for a second: I have yet to see one Republican emerge with a plan, or even a promise to create a plan, that will cover as many people, at as affordable a cost, with as comprehensive insurance, without increasing the deficit, as the Affordable Care Act. They see this, essentially, as a trojan horse. As Ben Domenech writes, "The only policies that could meet this waiver requirement are single-payer constructs."

Ben is being a bit hard on the GOP: Republicans used to have a proposal that could meet this requirement -- it's the one that Mitt Romney signed in Massachusetts. But then Obama adopted it and Republicans abandoned it without thinking up a replacement. Wyden-Brown, however, might get us to a much more productive stage in this debate. If conservatives are out of ideas for a universal health-care system that's as affordable, universal and comprehensive as the Affordable Care Act, which condition would they like to sacrifice?

Some say that universal health care should not be the goal. I disagree with that, and so too, I think, do most Americans. So the more common conservative critique has been that the health-care plans envisioned by the Affordable Care Act are too lavish. As Stuart Butler wrote, Wyden-Brown "locks the states into guaranteeing a generous and costly level of benefits."

You hear this a lot, so it's worth looking at it more concretely. The ACA subsidizes low-income folks so they can get health insurance that doesn't include much cost sharing, as the problem with not having much money is that it's hard to pay large medical bills. But for the rest of us, our plans only have to hit a 60 percent actuarial value. That means that they only have to cover 60 percent of our expected medical bills over the course of a year -- a level of generosity that's far below what most employer plans offer. For a typical family of four, the minimum plan would include up to $12,500 of annual out-of-pocket spending. Some of that would be in premiums, some of it in deductible, some of it in co-pays. But put all that together and it's not a very lavish plan. It's much stingier, in fact, than what most Americans currently have.

Which doesn't mean it shouldn't be stingier yet. Perhaps the $12,500 is too low. But how much higher? And why? This is a productive debate to have, as it gets to the core issue of what health-care reform should be doing. But it's not the one we've been having. Rather, there have been a lot of disagreements, complaints and misrepresentations of the Affordable Care Act paired with a vague promise to replace it with legislation that would do all the popular stuff at a lower cost and with less governmental intrusion. The reaction to Wyden-Brown is showing how unlikely that is. So perhaps we can move forward to the next phase of the debate and learn what it is that Republicans would like to do, and how many people it would cover, with what sort of insurance and at what cost. If Wyden-Brown isn't flexible enough, what would be?

Photo credit: Robert Giroux/Getty Images.

By Ezra Klein  | March 2, 2011; 2:17 PM ET
Categories:  Health Reform  
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Next: 'Sometimes it's useful to have multiple small programs'


Republicans want health care for people with enough money to buy some, and then take a tax break on the expense.

Everybody else? Do any Republicans really care whether they suffer from ill health and die young, as long as they work long hours for low pay until that time?

Posted by: S1VA | March 2, 2011 2:52 PM | Report abuse

Phase 1: Tort Reform
Phase 2: ?
Phase 3: Cheap, affordable, universal health care for all Americans.

Posted by: workmonkey | March 2, 2011 2:53 PM | Report abuse

I'm pretty sure the kind of health care reform the Republicans really want is SHUT UP!!

Posted by: willows1 | March 2, 2011 3:01 PM | Report abuse

you're probably right but theoretically they could get to ACA or better with a combination of open enrollment guidelines (see no individual mandate) and an end to pre-ex and strong capitation like is being done in MA.

Would they actually go there. Nobody with any sense believes they would.

In another lifetime they would have gleefully accepted Wyden/Bennett. But not today.

Would Wyden/Bennett be more deficit neutral than ACA?

Posted by: visionbrkr | March 2, 2011 3:04 PM | Report abuse

Ezra says "Some say that universal health care should not be the goal. I disagree with that, and so too, I think, do most Americans."

I think "no universal health care" is exactly the conservative's goal.

Posted by: PattyP1 | March 2, 2011 3:09 PM | Report abuse

I think the GOP has been pretty clear about what they want.
1. Medicare continues for existing recipients with no cost-benefit or means testing or end-of-life counseling.
2. Get rid of Medicare for future recipients (deficit reduction).
3. Health plans sold across state lines, so we can get a race-to-the-bottom in consumer protection, as we already got with Delaware incorporation and South Dakota credit cards.
4. Tort reform to take away a source of funding for the Democratic party.

None of this has anything to do with "covering everyone" which would be a handout to the poor, whom Jesus hates. (If he loved them, they'd be rich. QED.)

Posted by: FosterBoondoggle | March 2, 2011 3:13 PM | Report abuse

Asking what health plan the GOP wants misses the point entirely. The majority of the GOP establishment faithful wants the federal government to get out of the safety net business entirely. The only reason they don't come out and say this is they know even the rank and file Republican won't support that. So instead, we get this endless charade where they continually criticize any existing plan as being too (insert the reason du jour here). You cannot do hostage negotiations in good faith with someone who ultimately wants the hostage dead. To the extent the GOP seems to be bargaining at all, it is purely motivated by the other ulterior motive of the GOP establishment - to get re-elected.

Posted by: truthwillout | March 2, 2011 3:43 PM | Report abuse

Race to the Top - Health Care Reform Edition

Posted by: JERiv | March 2, 2011 3:53 PM | Report abuse

I could have sworn the GOP plan was "Don't be poor and sick, suckers!"

Posted by: will12 | March 2, 2011 3:56 PM | Report abuse

Health insurance and access to health care is becoming just another social class marker. Look at the language used to describe government employees' benefits, that they are the "protected class," etc. More and more people feel economically vulnerable, and that anxiety is totally playing out in the health care debate. I do wonder if many who are against universal health care feel that way out of an assumption that health care, like the job market and schools (primary and secondary), is increasingly becoming a zero-sum game between the haves and have-nots.

Posted by: nickthap | March 2, 2011 4:19 PM | Report abuse

truthwillout: you are exactly spot on. That's why Ezra's column is getting boring, because he has to assume (in order to have something to write about) that the Republicans are debating this in good faith. They're not.

The bigger question is, do Republicans also want to gut public education too? Sometimes it seems so. Governor Walkers new budget plan for Wisconisin cuts state education funds, but then also forbids local governments from raising property taxes to make up the difference. The happened in Texas a few years ago, and now districts like Austin (where residents would probably approve a property tax increase for the sake of schools) are forbidden to raise taxes and 1000 teachers are losing their jobs.

Posted by: nickthap | March 2, 2011 4:28 PM | Report abuse

Ezra, why bother even asking? You already know that readers' answers will be the correct one, which is that the condition Republicans want to drop is universal. And you know why too: every political move they make is always to try to protect the wealthy from the poor.

Posted by: JF11 | March 2, 2011 4:33 PM | Report abuse

I think this modified Ben Domenech quote really sums up the state of affairs:

"The only policies that will cover as many people, at as affordable a cost, with as comprehensive insurance, without increasing the deficit, as the Affordable Care Act are single-payer constructs."

That is another way of saying that the ACA is pretty darn good and the only thing better is the one that liberals want. The very conservative Ben Domenach is admitting that liberal ideas are better. But, he says this as if its a bad thing. That's because all he cares about his team "winning" where "winning" is not defined as what is best for the country, or who has the better idea, but simply, "my team beat yours."

People live and die by such policies but the GOP take it about as seriously as a college football game between rival schools. Where your school colors and root for your team even if you know the other team is better.

Posted by: nylund | March 2, 2011 4:59 PM | Report abuse

Republicans want to eliminate the 35 million people whoa re expected to get insurance due to health reform therefore killing 35,000 people each year.
They don't want sick people to be able to get health insurance because then they'll get in the way of rich people who need face lifts and liposuction.

Posted by: mynameisblehbleh | March 2, 2011 5:18 PM | Report abuse

The answer to this question has been apparent for quite some time. What the Republicans want and what they have preyed on is failure for the Obama administration. Instead of acting as patriots and statesmen, conservatives in this country have given in to a mean spirited and stunted mentality. This is their appeal. It is racism, but it is worse than that. It is the dispicable mindset of cowards appealing to the support of fools. They see the failure of this government as their highest purpose. They are contemptible.

Posted by: buddecj | March 2, 2011 5:50 PM | Report abuse

@nickthap and @JF11

Exactly. I like this blog a lot for the fact that Ezra covers a deeper policy angle than most anyone for some subjects (including health care policy), but it's totally true that he kinda has to keep pretending that there are any Republicans who actually want to have a good faith argument about this, and there just aren't. I'm not sure they can even have a good faith argument with themselves. Their voters all want to keep their Medicare and not have their (or their parents') SS checks shrink, and god forbid we stop trying to colonize the world. So they go after things that liberals like and poor people need, and if that only makes up 5% of the budget and 20% of the deficit, well, the answer is more tax cuts!

Posted by: goodepicwashpost | March 2, 2011 8:19 PM | Report abuse

It is hardly worth paying for plans with 60% actuarial value. FEHBP has actuarial value of 83%. I can't see what the benefit of subsidizing the private market is when the government can do a much better job.

Posted by: zosima | March 3, 2011 3:26 AM | Report abuse

Ezra: From the WSJ, March 1st, John Calfee:

"In a mere four years, Massachusetts has demonstrated that the most important effects of its reform arise not from the letter of the law but from the law's unintended and unpredictable consequences. The state is lurching from one crisis to another as it attempts to construct a system vastly different from any seen before or anything contemplated when reform was first passed. Health care in the state is evolving toward a state-run version of Medicare combined with government reorganization of the delivery of medical care.

The cost problem in Massachusetts is not going to be solved anytime soon. The question to be asked is why we should plunge ahead with a national version of this model before we learn whether Masssachusetts's brave new world is one in which we want to live,,,,"

Now Ezra, one wonders where, when and how the so-called "Affordable Care Act"-an oxymoron if one was ever coined-will actually deal with real-life problems of care access and cost controls. You and the other bill supporters can even pretend these issues are addressed, but that is a fiction. Not surprisingly, no Governor, Democrat or Republican, can claim to meet the fictional benefits this plan provides.

I suggest you read the rest of the article, as you, your Journolist friends, and your Democratic party insider allies need to develop more convincing spin.

Posted by: Towson_Tiger | March 3, 2011 8:27 AM | Report abuse

Zosima, you do realize that FEHBP is not an insurance program issued by the government? FEHBP has benefit standards set by the government (OPM), but the insurance is issued by private companies. It's not like Medicare, it's more like Medicare Advantage.

In FEHBP the government is not doing "a much better job" of anything other than making sure that the health insurance benefits for federal employees continue to be relatively rich.

Posted by: Policywonky | March 3, 2011 8:31 AM | Report abuse

Did you really have to quote that plagiarist Ben Domenech? I had hoped never to see his name in the Post again. Or was this some super-sophisticated dog whistle to the Left to underline the vapidity of arguments against ACA?

Posted by: Patroklus | March 3, 2011 9:47 AM | Report abuse

The Republicans want to free up health insurers to offer illusory insurance -- that is, insurance rife with annual and lifetime caps and a raft of exclusions. They probably wouldn't mind being able to claim that they had enabled millions of uninsured Americans to buy something that could be called insurance -- but it would be "insurance" that shifts the bulk of major risk to the policyholder.

Posted by: sprung4 | March 3, 2011 10:17 AM | Report abuse

Ezra writes: "The problem is, conservatives can't do any better -- at least not under these rules. This is an important point, so it's worth dwelling on for a second: I have yet to see one Republican emerge with a plan, or even a promise to create a plan, that will cover as many people, at as affordable a cost, with as comprehensive insurance, without increasing the deficit, as the Affordable Care Act. They see this, essentially, as a trojan horse. As Ben Domenech writes, 'The only policies that could meet this waiver requirement are single-payer constructs.' "

What a meaningless challenge to Republicans. Ezra and the Democrats say: “We’ve created this enormous, expensive, complicated, socialistic mess called Obamacare. We basically just declare that it covers everybody, though we can’t prove it because it’s not even up and running yet. And if you Republicans don’t come up with your own plan that gives every American health insurance (and is as “affordable” as our cooked-books estimate), you’re not “serious.” Right.

Here's an idea: Wouldn’t it be cheaper just to give those without insurance $12,000 each in cash with which to buy a health insurance plan every year? That should be enough, right? We’ll even use the liberal lie about 40 million uninsured. That comes to $48 billion each year. Heck, DOUBLE the payout. It would STILL be cheaper than Obamacare’s annual cost of about $100 billion (which is likely underestimated).

There, Ezra. I win. If America’s phantom 40 million uninsured can’t cover themselves and their family with an annual $24,000 check from the government, they are simply committing fraud.

(Disclaimer: As a libertarian and a fiscal conservative, I don't endorse this idea. It would horribly distort the market and drive up insurance prices, much like federal aid has caused runaway college tuition inflation. But it is an answer to Ezra's silly challenge.)

Posted by: jlakely | March 3, 2011 10:21 AM | Report abuse

Ezra, to start with, even the title of your article and the use of the words "health-care" reform plan, is one of the key issues that cause much of the problem we face in coming up with meaningful reform. Unfortunately, our president found it necessary to change the paradigm from "health-care" reform to "health insurance" reform. This was obviously not by accident and it shaped much of the contention and created a very narrow minded approach to coming up with real solutions.

Simply put, health care reform can't be put into some cute little 1200 page package and provide universal coverage, reduced costs and an acceptable level of quality care. Our government has moved way quickly to throw the current system out and move us in the direction of another government run, heavily taxed, inefficient universal health plan. The president, and apparently you, have challenged Republicans but your challenge is simply more politics wrapped in short sound bites that over simplify the real challenge--- "How do we better contain costs, retain quality (and competition) and take care of those citizens that are not financially able to have a reasonable level of health care”?

Posturing, threats and politics will not solve problems. Looking at the entire "health care system" and determining the role of government and doing everything possible to encourage a competitive market place with better oversight and responsible leadership will.

Brian Jolles
Ellicott City, MD

Posted by: brian45 | March 3, 2011 11:10 AM | Report abuse

*** that $12,500 does NOT include premiums ***
*** that $12,500 does NOT include premiums ***
*** that $12,500 does NOT include premiums ***
*** that $12,500 does NOT include premiums ***
*** that $12,500 does NOT include premiums ***

Posted by: sumipatel1985 | March 3, 2011 2:56 PM | Report abuse

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