Guest Contribution: “Why the Republicans Can’t Reform Health Care”

Today, we present a guest post written by Jeffrey Frankel, Harpel Professor at Harvard’s Kennedy School of Government, and formerly a member of the White House Council of Economic Advisers. A shorter version appeared in Project Syndicate.

Why do Republican politicians seem utterly unable to come together on a bill to “repeal and replace” the 2010 Affordable Care Act, also known as Obamacare? After all, they have spent 7 years with that as their single-minded goal, they campaigned on it in the 2016 presidential election, and they now control all branches of government.

It is tempting to blame lack of experience and competence on the part of the president. But that doesn’t explain why the Republican congress can’t do it without him. Some Republicans blame unwillingness of the Democrats to cooperate. But given their majorities it should not be necessary for the other party to cooperate in dismantling its most important achievement of the last eight years, nor is it remotely reasonable to expect them to do so.

Don’t be misled by the reasonable-sounding formulation that, since everyone agrees that Obamacare has flaws, a bi-partisan replacement to improve it should be possible. The most important of the existing flaws in Obamacare are there because Republicans insisted on putting them there, not because of unforeseen consequences of the original proposal.

It is a little closer to the truth to say that the Republicans negligently forgot to formulate an acceptable replacement in all their years of voting to repeal Obamacare. But that makes it sound like they could come up with an acceptable replacement if they tried hard enough. They cannot.

Republicans in Congress are divided. Whatever version of the bill they try out, they cannot seem to put together the necessary majority. But the familiar distinction between “hard-core conservatives” and supposed “moderates” is not the most useful way of looking at the split. They are divided, rather, between those who acknowledge the laws of arithmetic and those who do not.

By the way, it is the same division that has plagued the Republicans over tax policy for almost 40 years: they all want massive tax cuts but some also proclaim their commitments to pay down the national debt while preserving military spending, social security and Medicare, while others recognize that this combination is arithmetically impossible.

When Republicans say they want to repeal and replace Obamacare they mean not just a change in name, but a general reduction in the role of government in the health care system and, in particular, an end to the individual mandate that requires all Americans to have insurance. They are divided between those who recognize that the result of the various repeal and replace proposals would be a loss of insurance by many and are willing to accept this reality, on the one hand, and those who do not recognize it, on the other hand. The decline in the number of citizens who have coverage would exceed 20 million, according to the estimates of Congressional Budget Office (which, contrary to some desperate claims, have a very good track record).

An example of the first category is Rand Paul of Kentucky, one of the few more-or-less-consistent libertarians who deserve acknowledgment for intellectual honesty. But if his policies prevailed, the losses inflicted on lower- and middle-income workers would be so severe that the Republicans would probably be voted out of office for a generation. [That logic assumes that there still exists some limit to the scope for large numbers of Americans to vote against their self-interest.]

The second category of Republicans finds the loss of health insurance by 20 million citizens unacceptable. This group still doesn’t know what it wants, even after all this time. Some of them may take refuge in a solution where millions end up on skeletal health care plans that don’t offer true protection against the cost of serious health problems, so-called junk insurance. But this solution is no more attractive than the loss of coverage altogether.

Logically there should be a third group that acknowledges the arithmetic, finds the loss of 20 million uninsured unacceptable, and then chooses to face reality by working for a version of Obamacare or some other plan that can continue to expand the numbers of Americans who have health insurance. This third group would properly be labeled the moderate Republicans. Unfortunately there is nobody left in this group (except perhaps Susan Collins of Maine).

The individual mandate is a key component that makes Obama’s Affordable Care Act work. Many forget that it was originally an idea that conservative think tanks developed in order to devise a workable system of national health insurance with the minimum possible role for the government and a maximum possible role for the market. It played the key role in the Massachusetts health care reform signed by Mitt Romney when he was Governor in 2006. (Analogously, two more ideas originally designed by conservatives to achieve agreed goals in a market-based manner were the negative income tax and cap-and-trade environmental regulation.)

Consider a birds-eye perspective on alternative health care systems. At one polar extreme is socialized medicine: the government directly provides health care to all. The British are attached to their National Health Insurance. But different nationalities have different preferences. Nobody in US politics is arguing for a government takeover of the health care system, (even though some opponents of Obamacare have falsely described it in this way).

Who supplies health care is a different question than who pays for it. A substantial fraction of Americans would support a single-payer system. It can be described as “Medicare for everyone.” Other countries like Canada make it work, delivering high-quality health outcomes at a fraction of the cost of the US system. Advocates point to cost savings from paperwork reduction, for example. Still, it would be unrealistic to think that US government health insurance for all would be anything other than a very expensive new mandate – at a time when voters are unwilling to pay the taxes that would be necessary to finance the level of mandates that we already have. Certainly it will continue to be opposed by three influential groups: the insurance industry, those consumers who are happy with their current employer-paid plans, and Republicans in general.

What would the oppose polar extreme look like, a system where the ethic of “personal responsibility” insists that nobody gets health care unless they or their employers pay for it? It is hard to imagine such a system. It is not what we had before Obamacare; that system was not a model of personal responsibility. The uninsured imposed costs not just on themselves but on the rest of us as well, in ways that go well beyond expensive medical attention in the emergency room. Those who don’t see a doctor regularly are more likely to fall victim to alcoholism, obesity, smoking, and addiction to opioids or methamphetamine. Even leaving aside the emergency room, many of the uninsured end up receiving some longer-term care for which hospitals are not reimbursed so that they must spread the cost to the rest of us.

If the objective were to stamp out such nefarious practices it would require an active reversal of government policy, to stop the medical profession from providing care that it feels ethically committed to provide. Taking government policy out of health care would include depriving non-profit hospitals of their tax-exempt status, for example. Perhaps there could be a new federal law requiring ambulances to leave accident victims by the side of the road unless they can show proof of health insurance. I have yet to meet a free-market conservative so extreme as to favor such a system, when pushed.

So, as often, the right answer must lie somewhere between the polar extremes (socialized medicine at one end and a pursuit of pure laissez-faire at the other). It must have something like the key features of Obamacare. The famous three legs of the stool are: no discrimination against pre-existing conditions, the individual mandate, and a means to pay for it.

A heavy majority of Americans — including those who thought they hated Obamacare, at least until recently — want to retain the provision that insurance companies can’t discriminate against those with pre-existing conditions. [They also tend to favor the provision that parents’ policies must cover children up to age 26.] But they can’t have these popular benefits without also accepting the unpopular individual mandate. It is simply not financially feasible for private insurance companies to insure people who are already sick or at high-risk, if the still-healthy can opt out of the pool. The fundamental source of market failure is known to theorists as adverse selection. This is the origin of the famous “death spiral” that dooms plans lacking the mandate or something like it. The “no discrimination” leg won’t hold up the health care stool, if the individual mandate leg is removed.

So it doesn’t matter how many permutations of the legislation to replace Obamacare the Senate leadership tries. They won‘t come up with something that decreases the role of government without increasing the ranks of the uninsured.

This post written by Jeffrey Frankel.

64 thoughts on “Guest Contribution: “Why the Republicans Can’t Reform Health Care”

  1. pgl

    Excellent discussion. The link from this sentence is also worth the read:

    “They are divided, rather, between those who acknowledge the laws of arithmetic and those who do not.”

    Frankel also did an analogy about the ‘arithmetic’ of cutting taxes, raising defense spending, and somehow balancing the budget. The single word in Bill Clinton’s bio that Brad DeLong seized on was ‘arithmetic’ in reference to these budget battles.

    1. Steven Kopits

      But which arithmetic? Higher spending and higher taxes; lower spending and taxes; or increased spending and increased debt?

      The issue is not that the Republicans can’t pass repeal, but why they can’t repeal. And that reason is clear: the US economy no longer has capacity to support another expensive entitlement program, even as Obamacare has enshrined that expectation that it can.

      With paltry productivity and population growth, a rapidly aging population, and a structural deficit of not quite a trillion dollars (30% less, in fact) at the very top of the business cycle, the resources — or the hope of acquiring them later — are absent. Nor, despite Menzie’s fondest wishes, are marginal tax rates going up by 18% next year, or anytime soon.

      Thus, there are only two possible outcomes.

      First, Obamacare may be repealed in some form and a measure of fiscal balance may be restored, or at least the deficit deteriorates no further.

      Alternatively, Obamacare may be retained in some version without commensurate tax revenues, such that the cost is essentially borne by the deficit.

      In my article, Japan’s Lost Century (at the National Interest,; and with graphs,, I examine the link between Japan’s declining workforce, surging elderly population, declining GDP growth rate and falling interest rates. To all appearances, the Japanese government squared the circle by running up debt — bigly, as the President might say — to fund shortfalls in tax revenues to cover rising expenses. With interest rates low (effectively zero today), the cost of capital is all but free. Until it’s not.

      These pressures are now building in the US as well, most manifestly in exactly those states which I singled out earlier. The Federal government is also facing such pressures, save that it has a greater capacity to borrow. If Obamacare stays, the most likely outcome is a blowout of the deficit, which is frankly there in the CBO expected case anyway. The CBO’s forecast will just prove too optimistic, with revenues falling short and expenses ahead of budget, just as CBO’s revisions show this year. To wit, the CBO expected the 2017 fy deficit at $489 bn in Jan. 2015. By Jan. 2017, this had swelled to $559 bn, and only six months later, to a 2017 fy deficit of $693 bn. The chief culprits: income tax revenue 10% and corporate tax revenues 29% below expectations. The economy does not appear to have the taxable capacity the CBO anticipated. (Gives one some sympathy for Stephen Moore.) I’d add that interest expense came in well below expectations, just as I have suggested is likely to be the case in the future.

      Which way the economy goes may turn on a single vote in the Senate, and with it, perhaps the future of democracy in the country. I would like to be optimistic. The Japanese precedent warns of exactly the opposite. As a democratic society comes over the demographic top, its political leaders will lack the gumption to hold the line and cave to the ever-present deficit bias, once again secure in the knowledge that the some successor will have to address the issue well into the future. Alas, then we will be like Japan, secure for the moment, but living in dread of the reckoning which must surely come, sooner or later.

      1. d

        i see we have one vote for those who can pay for health insurance to get health care. and the end of employer provided insurance

        1. Steven Kopits

          Well, if you want my general opinion, I would:

          1. end the deductibility of healthcare insurance (ie, it would be ordinary taxable income)
          2. keep the exchanges
          3. keep the individual mandate
          4. move the high risk patients to a high risk pool, funded as a fixed budget quantity (ie, budget, not need, determined)
          5. keep the death panels
          6. focus on keeping working age people healthy for routine injuries, conditions

      2. Rick Stryker


        Very interesting article you have in the National Interest. Ultimately, I think you are saying that as the composition of the population gets older, you don’t have enough GDP to fund the programs that people will expect to have. As you mention, the US is facing a similar problem.

        1. Steven Kopits

          Glad you liked it, Rick.

          Your interpretation is correct. In the coming world, you can’t grow your way out of a problem, and we’re potentially going to have to make difficult decisions between fostering family formation and care of the elderly. My generation — the tail end of the Baby Boom — will be the most affected.

          All this is going to change the social compact materially. The notion that democracy will continue to bring increased prosperity year after year, that the government can always do more — these are ending, unless we see an unexpected pick up in productivity growth.

          It also changes fiscal policy. If interest rates approach zero, it is sorely tempting for a government to load up on debt if GDP growth cannot be assured and the elderly population is surging. That’s what Japan did, and that’s going to be the pressure than manifests itself in the US as well. It’s a big reason for the structural deficit.

          Moore is right: We are looking at $1 trillion deficits as far as the eye can see, and we can’t grow our way out of them very easily. And we’re looking to launch a major entitlement program into this context. I appreciate the quite calm of Susan Collins, but she should be more honest and suggest we raise the payroll tax by a third if we really want these programs. Then we’ll see how much we really need a new entitlement.

          1. baffling

            “you can’t grow your way out of a problem”
            supply siders believe exactly in this premise. tax cuts will create growth that will compensate for the lower rates. if you believe in your words, then you need to understand the statements from those like kudlow, moore, stryker and peak are wrong.

            we have lived in a world where technology and demographics have pushed growth, which in the past has solved a lot of problems. some on this board believe that same growth should continue. but the technology and demographics are not providing the same tailwinds as in the past. policies that worked during an era of aided growth probably are not the best solutions in an era where growth will be smaller without such tailwinds. supply side economics in an era where the natural growth rate is low is probably not the optimal policy.

          2. Steven Kopits

            Tax policy is separate from demographics, Baffs. It comes down to getting the elasticities right. That’s why I never bit on Kansas. Cuts were too big to compensate with better economic performance. The Republicans’ weakness in analysis and communication is really stunning, let me add, including — or maybe especially — on the national level.

            In any event, you can do both supply and demand side management (at least in theory) in an environment with both low productivity and population growth. It’s just that the coefficients are going to be different, as may be the associated regimes.

            For example, it’s not clear to me what QE in Japan is intended to achieve. If you have full employment and decent GDP / growth per worker, what do you want? Prices — at least for things like housing — will be deflating not due to monetary policy, but simply because demand is falling with declining population. It’s a real, not monetary, effect. So why the QE?

            Really, Japan doesn’t need lower interest rates. It needs more children.

          3. Rick Stryker


            I sometimes wonder if Pax Americana will go by the wayside in the coming long-term budget problems. That would be a tragedy of historic proportions. There never has been a country like the US, an essential force for peace and cooperation in the world. If America retreats, I fear for the world’s long term future.

  2. Veliladon

    The reason Republicans can’t reform healthcare is because Obama stole their idea. Obamacare is the 1993 Republican healthcare policy. They don’t have any ideas because Obama implemented the best idea that was already acceptable to them.

  3. PeakTrader

    The Republicans had plenty of time for a Obamacare replacement plan. Instead, they were just playing politics pretending to repeal Obamacare. At least, the Democrats have a plan – to gradually move towards socialized medicine, even if it means political suicide. Meanwhile, the American people, and the economy, suffer.

    1. PeakTrader

      The U.S. has an opportunity to make its health care system the envy of the world – even more innovation, even better outcomes (which when adjusted for apples to apples comparisons between countries is one of the best in the world), even better hospitals, equipment, drugs, specialists, nurses, etc.. And, all that can be maintained or improved at lower costs, while U.S. per capita GDP remains over $10,000 a year more than Canada, Britain, or other Western European countries. Of course, Americans are very dissatisfied with the current health care system, thanks to either our busy-body or do-nothing politicians.

        1. noneconomist

          PT: I doubt too many foreigners coming here would be satisfied with waiting six weeks for a cortisone injection like I was recently forced to do. Had nothing to do with the doctor but much to do with clerical misfits, administrative incompetency, and extended finger pointing on who was at fault.
          But, please, tell me more about how I’ll be waiting in line under universal health care or how long I’ll have to wait to get an MRI, an x-ray, or something as simple as a cortisone shot. Oh, wait…

          1. PeakTrader

            I’m sure, the doctor knows more about medicine than you. Maybe, the doctor believed you’re too weak to handle the side effects. Normally, the wait times in the U.S. is hours at the most compared to weeks or months in your universal health care world. There are many more medical devices per capita in the U.S..

        1. noneconomist

          PT: Oh really. The doctor SAID he would have given the injection on the spot but that it had to be approved by insurance first.
          If you read what I said, you would have a clue. But please, continue to enlighten me about how I may be too weak for cortisone shots, which I’ve revived regularly in the past. Maybe you should think twice before opening your mouth about that of which you’re blissfully ignorant. Of course, maybe your mind is too weak to do that.

          1. PeakTrader

            You said nothing about insurance before. Your mind is so weak, you expect people to read your mind. Doctors offices, clinics, and hospitals also have administrators and clerks. I doubt the doctor would wait for insurance approval if it was life or death. Couldn’t you have paid for the cortisone shot and get a refund later? It all seems very weak.

          2. Robj

            Peak Trader knows all, except he doesn’t know anything about how our supposedly greatest, yugely great insurance doesn’t “work.”
            Because all those Canadians are swarming over the border to get insurance here. Not.

  4. PeakTrader

    I think, an appropriate analogy for health care is hotel rooms. Do we want to socialize hotel rooms and have everyone stay in a one star hotel room? It’s sufficient, free, and better than a shelter. If that’s all there is, you won’t know what you’re missing. However, many, if not most, people do pay more for a better hotel room – a two, three, four, or five star room. Should someone with no money or unwilling to pay stay at a five star hotel room? Is that fair and can a country afford it? We should allow people, rather than government, to choose and we can provide a safety net that’s better than socialized medicine’s one star hotel rooms. Competition and choice will raise quality and drive down prices. Excessive regulations, including mandates and restrictions, are unnecessary and too expensive, and we don’t need divert huge amounts of money to lawyers. Of course, many will argue it’s unfair that some people, in America, have better health care than others, even if the worst health care is better than the socialized health care of the masses in other developed countries.

    1. baffling

      making an analogy between health care and hotel rooms is plain stupid. i shows a complete lack of understanding for the importance of health care.

      in addition, peak, almost all of your modern advances in health care technology have come from government funded research paid for through taxes which even the poor must pay a portion. but you want to create a system where wealth will be required in order to benefit from those advances. rotten.

      1. PeakTrader

        Baffling, you’re too closed minded to even begin to understand the analogy. It’s almost all about big government, socialism, and bureaucrats to you. You remain in denial about the extremely suboptimal and failed systems you support. You’re a danger to society.

        1. baffling

          peak, you are in favor of moving 25 million people off of health insurance and raising the premiums for the remainder. that is the result of your proposed fix. that is a danger to society. interestingly, you have no problem receiving your government provided medicare from the backs of todays healthy folks paying into the system. you embrace socialism and apparently are not even smart enough to understand your position.

          1. PeakTrader

            Baffling, it’s amazing how you can write an entire paragraph of nonsense and expect anyone to take you seriously. I doubt there are many greater fools.

    2. d

      odd, that other countries health system is actually better than ours. so its like we pay 4 star hotel rooms, but get at best 2 star rooms.

      we dont have the best health care. we just pay like we do. and thats based on results. not cost

      1. PeakTrader

        Even the WHO ranked the U.S. #1 in capital (hospitals, equipment, supplies, etc.), and #1 in labor (doctors, nurses, specialists, etc.).

        However, the WHO also ranked the U.S. below Cuba, because it believes an equal one star system is better than an unequal five star system, although no one in the U.S. is turned away from emergency health care.

        You get five star health care in the U.S. whether you pay for it or not.

      2. PeakTrader

        And, the reality is no country (at least, with a population over 1 million) can afford equal five star health care.

      1. PeakTrader

        That’s you and your one size fits all mentality. The real world is the sum of different individuals.

    1. d

      are you sure its not? that site isnt without its on biases is it?

      while having insurance doesnt mean you get care, but then not having it means not getting care at all.

  5. Beeker

    Over the years the Republicans have put out at least seven different versions of their own plans that were actually political documents designed to say they have a plan when they really don’t have one. Even the Heritage Foundation disavowed its plan after DeMint became its head.
    Am I surprised that they would have a hard time rolling it back? No even John Boehner, former Speaker, have said twice the Republicans never had a plan but it was the conservative organizations drove the debate about rolling it back something about freedom- ignoring the fact many of the supporters are the people who are benefiting from it.

  6. 2slugbaits

    The most important of the existing flaws in Obamacare are there because Republicans insisted on putting them there, not because of unforeseen consequences of the original proposal.

    Exactly. This is a point that doesn’t get enough attention, so I’m glad Prof. Frankel included it. It’s like pissing in your host’s punch bowl and then telling everyone at the party how bad the punch tastes. It’s easy to forget that Sen. Grassley was caught on tape bragging to his supporters how he tricked Obama into thinking that Grassley was genuinely interested in improving the ACA when all along he was just trying to run out the clock and insert poison pills into the bill. It’s easy to forget that when Sen. Coburn offered a few constructive suggestions to improve Obamacare he was told by Sen. McConnell to sit down and shut up and reminded that the goal was to make Obama a one-termer and not to try and pass a good health insurance plan.

    1. Rick Stryker

      Actually, this was one of Jeff’s strangest claims. How can Republicans be responsible for Obamacare’s most significant flaws when no Republican supported or voted for the bill?

  7. randomworker

    Any politician that ever decried the “uncertainty imposed upon our economy by Obamacare” oughta be horse-whipped in public right about now.

    It should be obvious to everyone by now that we are not going to stand by while some kid dies of a treatable illness. So let’s be honest. How do we pay?

    The doddering Donald promised better health insurance, cheaper, to more people, with lower deductibles and less out of pocket. Anybody believe this is where McConnell and Ryan are headed? Anyone?

    If you want the older people to pay more for their own health care then just say it. If you want insurance companies to be able to discriminate just tell us. If you want poor ppl to tough it out on charity wards like in Pakistan then say so. But nobody has the guts.

    1. Robj

      Peak Trader apparently believes it. It took a black Kenyan to make Romney/Heritage Care toxic because. . . . well, Republicans really didn’t want a rational health care system–they would prefer none at all.

  8. ivars

    Foxconn factory in Wisconsin surely is a mistake and lie and the whole thing will turn out as harming the people of Wisconsin and embarrassing for Trump.

  9. Tom

    You seem to think that the federal government is somehow responsible for everyone’s healthcare. We’re a constitutional republic. Why can’t the people of Indiana come up with their own health care plan that best suits the needs of Hoosiers? Why get the federal government involved? We have 50 laboratories of democracy. Let them experiment, without heavy handed mandates from the federal government.

    Now Slugs is going to chime in and say state governments are corrupt, the idea of federalism is dead, etc. The Constitution is the law of the land. Period. If you don’t like the system of government it created, change it. But don’t claim powers that don’t exist. If federalism is dead, what rules do we play by? Whatever the Democrat party thinks feels good?

    1. baffling

      tom, you are spending too much time in the conservative echo chamber! turn down rush and sean. they are entertainment hacks after ratings and drama.

    2. 2slugbaits


      State governments are corrupt and federalism is dead. Actually, the original federalists wanted to abolish the state governments, but while Madison agreed with the sentiment, he thought it was politically a non-starter. Better to pass the Constitution with a few sops to the anti-federalists (i.e., the folks that today would call themselves “federalists”) and let the commerce clause do the heavy lifting of allowing the states to wither on the vine. Try reading the correspondence between Madison and Hamilton. You would do well to learn a little history.

      In any event, the SCOTUS has ruled that the federal government can tax people in order to pay for medical insurance. The Constitution does not prohibit the federal government from making healthcare a right. You might want to re-acquaint yourself with the Ninth Amendment. It makes a distinction between enumerated and unenumerated rights. Healthcare is an unenumerated right.

      As to the 50 laboratories, did you forget that Obamacare was just a nationwide expansion of Romneycare? We have experimented. The Mississippi model fails and the Massachusetts model succeeds.

    3. Rick Stryker

      Indeed you are right Tom. It would be much better to let states experiment with the programs that they think their populations want. Blue states could have highly regulated systems, perhaps even single payer if they wanted, while not forcing everyone else to come along. We’d then see what works, what doesn’t, and what the tradeoffs are.

  10. efcdons

    “So, as often, the right answer must lie somewhere between the polar extremes (socialized medicine at one end and a pursuit of pure laissez-faire at the other)”

    Not really. As you state earlier in the piece, one “polar extreme” (the NHS), works in reality and provides quality coverage to all. The other ” “polar extreme” (die in the street) exists nowhere, at least in the developed world (I guess it exists in somewhere like rural Democratic Republic of Congo or some other extremely poor country).

    So your statement “the right answer must lie somewhere between the polar extremes” doesn’t refer to the actual operation of at least one end of the polar extremes. What is it that makes the “right” answer somewhere between the two when one “extreme” is a possible “right answer” considering the goals of a health system?

    Politics. You briefly touch on why (“Certainly it will continue to be opposed by three influential groups: the insurance industry, those consumers who are happy with their current employer-paid plans, and Republicans in general.” ). And really, you’re only right about the insurance industry and republicans because people actually don’t love their employer provided insurance (

    Employer provided plans are less popular than every government provided plan from Medicare to Medicaid to the VA. So since people on government plans right now like government plans more than people on employer provided plans like employer provided plans, why would switching those on employer provided plans to government plans create some huge amount of resistance? I know people with an employer plan like the one provided to a professor at Harvard probably love it (I hear you, I grew up on a plan provided by an elite research university too since my dad is a professor of medicine at one of the top medical schools in the country. The one time I had to use the insurance it was all private rooms, immediate treatment by top doctors, never ending bowls of ice cream, and barely any out of pocket costs ). But for regular folks their employer provided plans aren’t so sweet.

    So essentially we are forced into less than optimal systems because of rich people and their power over our political system.

    The ACA was an attempt to buy those rich people off. And it didn’t work! They have been going after the ACA since jump and AHIP has done (apparently) absolutely nothing to try and save the ACA from the gop.

    So really, “the right answer must lie somewhere between the polar extremes (socialized medicine at one end and a pursuit of pure laissez-faire at the other)” isn’t operationally or even politically correct. Maybe instead of “right answer” which appears to make a broader claim than is reasonable you could say “barely possible” or “forced in to by our terrible political system which give overwhelming power to those most enriched by the current status quo”

  11. Rick Stryker

    Jeff is quite off base on this one. This has nothing to do with arithmetic or the three-legged stool. Some reactions to his comments and then my take on the Republicans’ difficulty:

    “Some Republicans blame unwillingness of the Democrats to cooperate. But given their majorities it should not be necessary for the other party to cooperate in dismantling its most important achievement of the last eight years, nor is it remotely reasonable to expect them to do so.”

    No lack of cooperation from the Democrats is key. Republicans can’t change the law in the Senate without 60 votes, which they are not even close to having. So they are forced to change it in stages. In the first stage, they can only change the budgetary aspects. That makes for a difficult situation since CBO will score “losses” in coverage, because they can’t take into account stage 2, regulatory changes, and stage 3, changes in the law. The fact that Republicans can’t vote on the whole package at once makes it hard for them to support stage 1, because they can’t be sure about the other stages.

    “The individual mandate is a key component that makes Obama’s Affordable Care Act work.”

    Yes, and that’s been one of the key problems with Obamacare. As I’ve pointed out over the years in these comments the individual mandate was not powerful enough to make the system stable. If the voters really wanted a swiss-like system, they could have had that if they were willing to accept a powerful mandate i.e., the fine is larger than the cost of insurance, etc. The reason the Democrats did not put in such a powerful mandate is that they could not do it politically. They ended up putting in a weak mandate and convinced themselves that it would be good enough since people would naturally want to buy the insurance. That was wishful thinking. Instead, they lost the House. People hate the mandate.

    “Many forget that it was originally an idea that conservative think tanks developed in order to devise a workable system of national health insurance with the minimum possible role for the government and a maximum possible role for the market. It played the key role in the Massachusetts health care reform signed by Mitt Romney when he was Governor in 2006.”

    I’ve gone through the history of this in previous comments. Some conservatives proposed a mandate back in the late 80s but by the early to mid-90s those who had proposed it retracted and conservatives came out solidly against the mandate.

    “Other countries like Canada make it work, delivering high-quality health outcomes at a fraction of the cost of the US system. ”

    I was in Canada recently and I asked my Canadian dinner partners what they thought of the Canadian system. One story people told me was the friend who had some very bad, cancerous symptoms that he needed imaged. If you don’t treat this kind of cancer, you’ll be dead in 6 months. The Canadian system put the friend on the waiting list with a 6-month expected wait. What did he do? He called the doctor, paid $500, and got the test on Wednesday. People at the table also talked about how Canadians with serious problems come to the US and pay. The poor Canadians, however, can be out of luck.

    Here’s my take:

    The problems the Republicans face is not about arithmetic. It’s about politics. The public never wanted a swiss-like system with a true mandate. The Democrats gave the voters a watered-down swiss system with a weak mandate and then expanded Medicaid significantly. The weak mandate created a peculiar death spiral that is converging to an equilibrium in which only the very sick or the very poor can buy insurance on the exchanges or get it free through Medicaid. Those people benefit from the system. Trump’s voters (and probably many of Hillary’s too), whose incomes are above the 400% poverty line, are being priced out of the individual insurance market–the Democrats destroyed the personal insurance market for them. That’s why Trump’s message of “repeal and replace” immediately worked so well for him.

    The politics of this problem is very difficult. People hate the mandate and no Republican wants to raise it get more healthy and young people in the market. Without a politically unacceptable increase in the mandate, the problem of unaffordability of insurance for the non-poor can’t be solved without a radical overhaul of Obamacare. But, as I already pointed out, the Republicans can’t radically overhaul the system because of the filibuster. They can only make budgetary changes which must necessarily cut benefits, at least in the short run, to those who are subsidized in the system. Naturally, they don’t want to do that.

    Democrats gambled Congress to push in a huge new entitlement. They lost Congress ultimately but they did get the entitlement they wanted. We are seeing once again that once the government gives out an entitlement it’s very, very difficult to take it away.

    1. 2slugbaits

      Rick Stryker Some conservatives proposed a mandate back in the late 80s but by the early to mid-90s those who had proposed it retracted and conservatives came out solidly against the mandate.

      They did more than propose it; Romney actually signed it into law. You remember Romney, don’t you? Just to refresh your memory, he’s the guy you voted for in 2012. And the fact that conservatives retracted their support for Romneycare says a lot about their moral cowardice and absence of integrity. Retracting something doesn’t change the fact that they supported it.

      The Canadian system put the friend on the waiting list with a 6-month expected wait. What did he do? He called the doctor, paid $500, and got the test on Wednesday.

      Smells like an urban legend. I can’t tell you how many times I’ve heard this exact same story repeated over and over and over again. Next time you have dinner with those folks I suggest you turn on your BS detector. You were played with a cock-and-bull story. And do you really believe that a doctor can just do an imaging test for $500??? Get a clue.

      I agree that the mandate should have been much higher.

      Democrats are under no obligation to support the Republican attempts to repeal Obamacare. If the GOP were genuinely interested in fixing Obamacare (e.g., increasing the mandate), then the Democrats would jump at the chance. But the GOP fed their braindead base lots of red meat and can’t walk away from the “repeal” promise. Repeal was never a plan; it was just a political bumper sticker. But now reality is setting in and some senators are getting quite nervous.

      1. Rick Stryker


        I went through the history of the mandate in conservative circles in comments a few years ago. By the mid-90s, the mandate was anathema to almost all conservatives.

        Romney did support one for MA, but his support was not ideological, i.e., the three legs of the stool nonsense. Romney’s support for the mandate was a pragmatic alternative to raising taxes generally. Romney never supported a mandate at the national level. Romney believed the mandate and some other reforms were justified at the state level given the particular problems that Massachusetts faced, the most important being a requirement to change the way the state paid for medicaid or lose a federal waiver and $385 million in federal medicaid funding. But the mandate itself was specifically motivated by the fact that Massachusetts’ uncompensated care pool, which was supported by contributions from hospitals, insurers, state, and Federal funds, often could not fully reimburse hospitals for uncompensated care. Hospitals were complaining and Romney did not want to raise taxes in general. Romney wanted to shift the costs from the Massachusetts taxpayer by requiring the purchase of catastrophic insurance so that the cost would be borne by the people using the services. Catastrophic insurance was not defined in any prescriptive way in Romney’s proposal. Given that the mandate was for catastrophic insurance, it was not a huge burden on people. Romney also opposed the employer mandate and vetoed it when the Democratic legislature put it into the health care bill. Nonetheless, Romney’s support for the catastrophic care mandate, even at the state level, hurt him with conservatives in general and Romney’s support for it does not mean that it had general support among conservatives.

        It was not a cock-and-bull story. The person who told me the story was the father of a friend. He was very specific about the details, who he was talking about, and had no reason to make it up. I know many other Canadians who tell me exactly the same thing. The cash price for tests can be much lower than the regulated insurance price–that’s true in the US too.

        In the Canadian system, you wait for tests and procedures. For example, the the average wait time for a CT Scan is 4 weeks, 10.4 weeks for an MRI, and 4 weeks for an ultrasound. On average a Canadian will wait 23.2 weeks for a hip or knee replacement. For that small minority that can afford it, they will pay cash to jump the line or go to the US for treatment.

    2. baffling

      rick, you acknowledge that once obamacare became law it has been very difficult to get it back. so your best bet is to take what you have and make it better. instead the republican and conservative position has been, since i cannot get what i want, i will let you all suffer-trumps approach. in fact, i will go out of my way to make this fail. this is behavior i expect from a spoiled teenager. that is poor leadership. and a moral failure.

  12. CoRev

    This is how I see the issues. Most agree that the death spiral of Obamamcare is real due to : “I agree that the mandate should have been much higher. ” Such mandates are anathema to most conservatives and libertarians, but supported in their core beliefs by many/most liberals and progressives. That same political group wrote and passed,a monstrosity of a bill with this known death spiral and continue to blindly support it. Without changes Obamacare will die.

    Additionally, most entitlement bills (SSA, Medicare, etc) have independent revenue streams to support them until the number of entitled grows outside their range. This is a tax spiral which adds power to the implementing Governments, another anathema to most conservatives and libertarians, but supported in their core beliefs by many/most liberals and progressives. With these core political differences stopping change Obamacare will die.

    Compromise is the only answer. The original argument whether medical care should be a right was established with passage of Obamacare. It now needs to be modified with input from both parties, or it will die.

    Get on with it, or watch the voters speak again. If that happens, this conservative expects more movement to political extremes. Overall, Obamacare will then die.

    1. Menzie Chinn Post author

      CoRev: “Most agree the death spiral of Obamacare is real”. I don’t know in what universe “most” agree. CBO didn’t. Maybe you have a million minions sequestered somewhere that do.

      1. CoRev

        OK, Menzie, let’s just sit back and watch what happens without changes. CBO claimed earlier this year: “But the Congressional Budget Office, in a little-noticed part of its report last week, said that is not the case. In fact, the CBO analysts said, Obamacare’s exchanges are likely to “be stable in most areas” under the existing law.” (

        Does stable mean fewer and fewer insurers, higher and higher rates, with higher and higher subsidies paid?

          1. CoRev

            Menzie, is that (…who are these “most” you were referring to.) all you can muster? I thought Dr Frankel explained the “death spiral” very well, in explaining the Republicans legislative problems. Just to be clear, Dr Frankel started that paragraph with: “A heavy majority of Americans —…”.

            Did you have an argument with my analysis?

  13. Rick Stryker

    I agree with CoRev on this issue. I’ve argued in the comments over the years that Obamacare was flawed and would need to be fixed. After the 2014 elections, I mentioned in comments somewhere that the Democrats should fix Obamacare before the 2016 election, or Hillary would suffer for it. Given how close the election was, if they had fixed Obamacare before the election, I’m confident Hillary would be President today. Trump exploited the issue in a way that Romney, for whatever inexplicable reason, refused to.

    But I’ve also long suggested that the fix must be bipartisan. Legislation of this magnitude should have been bi-partisan in the first place. We’re in the mess we are in because the Democrats refused to bring the Republicans in and compromise on the plan. They were determined to go it alone and they put into place a program most of the public did not want. The Democrats payed a heavy price, losing Congress and as well as Obama’s ability to enact his agenda. They also got Trump instead of Hillary.

    Republicans have made the same mistake of trying to go it alone, and have been humiliated. To fix Obamacare, moderate Republicans must join with moderate Democrats to put together a hybrid system that combines ideas from both sides. To make this happen, Democrats need to acknowledge that there is indeed a problem. The obsession with the mandate and the “three legs of the stool” nonsense is symptomatic of the obtuse blindness that got the Democrats where they are. The public doesn’t want a mandate. The public never wanted a mandate. Therefore, the solution won’t include a mandate. We’ll need to be more creative than that. For example, you might put into place a requirement that you are covered for pre-existing conditions as long as you keep continuous coverage. However, if you drop coverage, you will have to wait a year to cover a pre-existing condition with a new plan. But you will always have the right to buy a plan even if you have dropped coverage. It might be possible to drop the mandate with such a provision.

    At the same time, Republicans will have to acknowledge that the Democrats have succeeded in creating a new entitlement. It will not go away. No one is going to take away the insurance that people already have in any significant way. In any bi-partisan fix, the people who have subsidized plans as well as Medicaid will have to be protected by and large although certainly some details will likely have to change.

    Moderate Democrats and Republicans agree more on health care than they disagree. I could see Trump making a deal with the Democrats on this. I hope he does–Obamacare must be fixed. But the politics is hard to see. The Democrats might refuse to deal at this point, hoping that Trump’s voters will be hopping mad that Obmacare did not become affordable as promised, and will vote Democratic. We’ll see.

    1. efcdons

      “We’re in the mess we are in because the Democrats refused to bring the Republicans in and compromise on the plan. They were determined to go it alone and they put into place a program most of the public did not want. ”

      The flagrant and brazen lying by gop supporters is just breath taking. The Gang of Six deliberated for months. The gop introduced dozens of amendments and a number were included in the bills in both the House and Senate.

      “During that markup, about six Republican amendments were adopted via roll call vote, and others were adopted by unanimous consent, without objection, and via voice vote, according to coverage by Congressional Quarterly. Parts of this bill merged with the bill the HELP committee marked up to become the final law.”

      “On the House side, some Republican amendments to the Affordable Care Act were accepted in committee; 24 Republican amendments were incorporated in the Energy and Commerce Committee, and six were incorporated in the Education and Workforce committee. ”

      The idea Obama and the Democratic legislators “refused” to bring in the gop and compromise on the plan is just not true.

      1. baffling

        are you surprised by this revelation? rick stryker has gone on record supporting the idea of lying to win your battle. he has no problem sleeping at night after writing a falsehood which could promote his ideology.

      2. Rick Stryker

        You selectively and misleadingly quote from the article you linked to and then accuse me of lying? Let me add a few more relevant quotes from your own article:

        “We decided to look into Gutierrez’s claim that the final version of the Affordable Care Act incorporated hundreds of Republican amendments.

        When the ACA was making its way through Congress, former President Barack Obama made a similar statement in September 2009. During a joint address to Congress, he said that his plan incorporated the ideas of both Republicans and Democrats. We rated that claim Mostly False, because many of the amendments Republicans introduced were technical in nature.

        “Timothy Jost, emeritus professor of law at Washington and Lee University School of Law, told us that “the basic statement that hundreds were adopted is wrong.”

        But Jost added that “there was very significant Republican participation early on on the Senate side. There were dozens of hours of debate, and Republicans like Sen. Chuck Grassley on the Senate Finance Committee were very engaged.”

        Jost said by September 2009 that period was over and from then on, the bill was strictly a Democratic piece of legislation.

        Let me add to that: NO Republicans voted for the bill. Scott Brown during the 2010 special election shocked everyone to become the first Republican since the 1970s, largely on the campaign promise that he would be the vote that would stop Obamacare. The Democrats were forced to proceed with the Senate version as a result, since they couldn’t go to reconciliation between the House and Senate bill as a result of Brown’s victory. The bill contained no Republican content other than technical amendments and attempts by the Republicans to stop the bill by offering unpalatable but politically impossible amendments to shoot down, such as the amendment that Congress and its staff would have to enroll in Obamacare.

        1. baffling

          so rick is worried if somebody other than a conservative republican or comrade trump lies. interesting. i see a double standard in the world of rick stryker.

  14. joseph

    Rick Stryker: “On average a Canadian will wait 23.2 weeks for a hip or knee replacement. For that small minority that can afford it, they will pay cash to jump the line or go to the US for treatment.”

    Always with the stories about hip replacements. Hip deterioration is generally a condition that takes years or decades to develop. It is not a life threatening condition. Doctors will generally predict when you will need it months ahead of time.

    It’s ironic that Republicans always bring up the hip replacement story since in the U.S. the vast majority of hip replacements are provided to seniors by government provided Medicare.

    1. CoRev

      Joseph, you just made a comparison between two single payer systems, Canadian vs US Medicare. Still you imply that Canadian medicine is better without refuting the 23.2 week delay in an elective surgery?

  15. joseph

    CoRev, let me use small words since you are failing to grasp the irony. Republicans’ favorite example of the greatest health care in the world is single-payer socialist Medicare for hip replacements. That’s irony.

    Why not this admittedly great Medicare for everyone?

  16. dwb

    Logically there should be a third group that acknowledges the arithmetic, finds the loss of 20 million uninsured unacceptable, and then chooses to face reality by working for a version of Obamacare or some other plan that can continue to expand the numbers of Americans who have health insurance.

    Lots of words here, almost all of them are beside the point.

    There actually is broad agreement on some healthcare issues. They way you expand access to healthcare and reduce govt involvement is to make it cheaper to deliver. For example, make it easier and cheaper to develop generic drugs. The trouble is that all that policy is outside the “budget reconciliation process” and could not be shoehorned into this budget process.

    Unfortunately, Democrats are just as much to blame for the current mess as Republicans, because they refuse to cooperate. Compromise means both sides give up something. If policy achieves it’s objectives – making heath care cheaper – then curtailment to the growth of Medicaid is going to happen. We may as well reflect that fact in the 10 year budget, which is a quasi-fiction anyway. When people get up on a podium or post on a blog and tell me people will die because we curtail Medicaid growth 5 years from now, I know that they have lost the argument, as do most the rest of Americans. Before people take a victory lap over Republican’s inability to achieve a consensus, they should remember Democrats have been punished at the ballot box for 7 years over Obamacare. Democrats won’t be seen as heros for grinding Congress to a halt. Unfortunately, Democrats are still playing from the 2016 losing playbook.

  17. Lord

    Republicans wouldn’t compromise originally because they hoped to defeat it. They wouldn’t compromise now because they hoped to repeal it. Even if some are willing to compromise now, it is doubtful their leadership would allow it, a majority of the majority and all that. The only way they will compromise is if they become a minority party again with weakened leadership.

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