Conservatives have been mesmerized by the discussion of how we find a way to roll back the Affordable Care Act, President Obama’s signature legislation. The number of pages written on the subject must be in the millions.
And despite that, Philip Klein‘s book, Overcoming Obamacare, does a better job than almost any of its predecessors to succinctly and aptly describe the hurdles conservatives face in reaching that goal. Even in the week since the book was published, many have written about their opinions about Klein’s view of the landscape. Just to give some perspective, I point you to my favorite reads on the subject from Mark Hemingway, Aaron Carroll, Veronique de Rugy, and Ezra Klein. I believe it is well worth a read for health policy experts, politicians, and average citizens that want to get their heads around the very complicated and important subject. And frankly, at $2.99 on Amazon for the Kindle version, it is readily accessible to everyone.
Klein begins the book by providing a nice synopsis of the evolution of the ACA, what Democrats intended to achieve from the beginning, and the multitude of compromises they made to get the complicated ‘Rube Goldberg’ (Paul Krugman’s words, not mine or Klein’s) system passed in order to achieve their long-term goal: single payer health care.
But where Klein’s book excels, and takes us past previous Obamacare books, is his breakdown of where the conservative attempts for pushing back the ACA’s government over extended regulations and restrictions stand. He concisely breaks down these political camps between the Reform School, Replace School, and the Restart School.
The Reform School proposes to roll back many of the taxes and regulations of the ACA, while not fully repealing the law wholesale. It’s biggest and most vocal proponent has been Avik Roy, Senior Fellow at the Manhattan Institute and Editor of the opinion page at Forbes. Roy has published an extensive, specific plan called ‘Transcending Healthcare‘, which lays out specifically how he would transform the current health care exchanges into a more free market system, reduce federal regulation and taxation, all the while providing more choice to American consumers, reducing the overall taxpayer costs in health care, while also covering more citizens than is currently expected to be covered under Obamacare.
As Klein notes, the harshest critics of the Reform School largely lie within the Replace School. The question ultimately lies upon how much you believe Obamacare can truly be repealed. Those that believe the entire law can be repealed, without any or little political cost, prefer repeal. Those, like Roy, who see complete repeal as unlikely because of the millions of people who would lose health care insurance under such a strategy, feel that a different path is necessary.
The Replace School, on the other hand, firmly believes that the entire Affordable Care Act can and should be repealed; and then, if that occurs, put in place a true conservative vision of free market health care. Led by such commentators as James Capretta of the American Entreprise Institute and Yuval Levin of the National Review, this group largely believes that we cannot reform the current system until the damage of Obamacare is remove. Capretta has written extensively on the subject, and has submitted his own extensive plan on the subject.
The most extensive proposal in this school, however, is by the Republican Senatorial triumvirate of Tom Coburn, Orrin Hatch, and Robert Burr. The Burr-Coburn-Hatch proposal would have completely repealed the Affordable Care Act, and replace it. This plan would have dramatically decreased federal regulations on states, allowing them far more leniency in developing their own regulations, while covering slightly more individuals than Obamacare while spending less money.
The final school Klein outlines is the Restart School. This school is most famously identified with Sen. Ted Cruz, although I would argue its biggest true propoents are Rep. Paul Ryan and Gov. Bobby Jindal.
Jindal, for one, has submitted the America Next proposal for health care reform. It was far more radical in its approach than the other plans listed here, largely because of its radical reform of the employer based system. As such, it requires the end of the Affordable Care Act, which is largely built on the employer mandate and the presumption that most Americans will continue to receive health care through their employers. It also in many ways requires the end of the employer sponsored insurance system that has been the foundation of health care in the U.S. since the 1940s. Therefore, it is hard to envision such a plan not to cause widespread disruption and anxiety.
As Klein admits, there are many whose positions overlap these three broad ‘schools’. However, I think Klein does a great service to conservatives by simplifying where the current conservative positions stand.
By providing a ‘gestalt’ view of conservatism’s health care positions, Klein allows many who don’t follow the specifics and intricacies of the health care reform debate to start to build a ‘ mental construct’ of how to approach the entire issue. I have found that those that are politically savvy but not necessarily knowledgeable about health care find this entire debate off-putting. In fact, I found this to be a common symptom of how Congressmen and Senators approach the issue; it is easier for them to use platitudes and generalities in their responses to health care reform, instead of truly understanding the cost and benefits of each strategy to reform the system.
I also think that for many, we have gone through an evolution on this. Four years ago, I would have definitely placed myself in the ‘Restart School’. I fundamentally didn’t believe that Obamacare could be adequately reformed, and therefore, only a complete overhaul was appropriate.
However, I personally believe that we crossed the Rubicon with the defeat of Mitt Romney in 2012. Once the exchanges and Medicaid expansion occurred in full force, we had lost the short-term window for a full repeal.
As of 2015, the landscape is far different than it was in 2012. Millions, in one manner or another, and for better or worse, have been insured under the Obamacare system, largely with subsidies and direct benefits from the government. It is possible to roll back these measures, but once started, that rollback will have to be incremental to be truly politically viable.
Klein’s book is a short, succinct tome that everyone truly interested in understanding the strategies necessary for conservatives to return health care to a free market model should read and try to assimilate into their own thinking process. I think it is now essential reading for all conservative politicos and Republican politicians, along with items such as Avik Roy’s health plan and Tom Coburn’s extensive writings on the subject. Conservatives need to, in short order, decide on a reasonable political strategy forward, while also balancing the most cost efficient, free market approach to health care that we can possibly pass into law. As such, Philip Klein’s submission to this literature is a worthy addition.