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The Health Care Repeal Fantasy

Ramesh Ponnuru has a long piece in National Review arguing that Republicans can indeed repeal the Affordable Care Act. The piece isn't totally unconvincing as a potential long-shot scenario. But it does suffer from a couple severe weaknesses. First, it dwells on the possibilities of gaining a House majority, but fails to grapple with the more important question of how Republicans could obtain 60 Senate votes. Since every Senate Democrat voted for the Affordable Care Act, Republicans will need to gain 19 Senate seats, in addition to the House and White House, to repeal the law. A related problem is that, as Republican Senate numbers increase, they become increasingly dependent upon winning purple and blue states, where Senators would be reluctant to endorse repeal. (Republican Senate candidates in Delaware and Illinois are already backing slowly toward the door.) Getting 60 GOP Senators by 2013 would be hard, and getting 60 who endorse repeal harder still.

Secondly, it glides right over the political problem of repealing popular elements of the act, especially the ban on higher rates for people with preexisting conditions. Ponnuru writes:

The most popular parts of Obamacare are the ones Democrats have most wanted to discuss. They are the eventual ban on insurers’ charging higher premiums to people with preexisting conditions and the reduction in out-of-pocket expenses for senior citizens buying prescription drugs. The preexisting-condition provision is central to Obamacare: To work, it requires making the purchase of insurance compulsory and subsidizing the purchase for people who cannot afford it. So Republicans cannot simply repeal all the other parts of the bill while leaving the ban in place.

The good news for opponents of Obamacare is that it will be years before these provisions are fully implemented — years during which there is no reason to expect them to overshadow the unpopularity of Obamacare as a whole — and the early steps toward implementing them will benefit relatively few voters. The better news is that Republicans can say that they favor addressing the problems of people with preexisting conditions without turning the country’s health insurance inside out. That message would be both appealing and true.

Appealing, yes. But true? To be true, Republicans would have to pair their repeal with the immediate enactment of another plan that addressed the problems of people with preexisting conditions. There were a few conservative plans floating about that claimed to accomplish this, but I have severe doubts that they were well-crafted enough to survive any legislative scrutiny. Moreover, none of these plans received anything close to the endorsement of the whole GOP caucus. Crafting a health care plan that can get 60 votes is very, very hard -- that's why the country went for decades with a dysfunctional health care system. And if the small, cohesive GOP caucus of 2009-2010 couldn't unite around a plan to address preexisting conditions -- a goal they all claimed to share -- I fail to see how a larger, more diffuse caucus could so so.

Indeed, I'm not sure Ponnuru actually thinks the Republicans would replace the Affordable Care Plan with a right-wing plan to address preexisting conditions, or even with any sort of alternative at all save the status quo circa 2009. Here he is, later in the article, laying out how Republicans should force Democrats to support repeal:

Some of them will try to say that they favor repeal with various caveats. To avoid this, Republicans will need to have sponsored specific repeal legislation. (Since almost nothing in Obamacare goes into effect this year, the legislation should be a simple, one-sentence repeal. Republicans have already voted for alternatives and can continue to talk them up, but the legislation itself need not “replace” Obamacare.) The test of whether a Democrat is truly against Obamacare will then be whether he co-sponsors this legislation.

So there's the real strategy: repeal the Affordable Care Act, full stop. But here's the problem. In 2009-2010, Republicans could oppose health care reform while saying they favored some painless alternative that would address preexisting conditions and other popular demands. If they're crafting a law to repeal the Act and they don't have an alternative, though, people are going to notice. Vague promises to address the problem somewhere down the line won't cut it. Alternatively, they need to find 60 Senate votes to both repeal the Act and replace it with an alternative that 60 Senators could agree on -- that's an extraordinarily complex challenge, with all sorts of regional pressure, interest-group lobbying, political calculation, and so on.

It's also worth pointing out that, under this scenario where Republicans have gained total control of government, public mistrust of government would go from being the Democrats' problem to the Republicans' problem. When you control the government, and the public mistrusts the government, the public mistrusts you. And public mistrust of government complicates anything the government does, including scaling back government. Of course, the economy may well be on the mend by 2013, which would diminish public mistrust of government, but in that case it's hard to see Republicans winning the White House plus a Senate supermajority.

Ponnuru emphasizes the self-fulfilling psychology of keeping the repeal flame alive: "Opponents and skeptics of Obamacare cannot become resigned to it as a permanent fact of American life." I suspect this is the spirit in which the article was written.