Republicans have faced a real health care problem for many years now, which is that health care just isn't their thing.
It's one of those "mommy" issues that liberals care about, while conservatives are much more likely to be interested in topics like tax policy or national defense. Yet throughout the Obama years, they've had to act like they both care about and understand the substance of this issue, when apart from a few conservative wonks here and there, they'd really rather spend their time on other things.
And after telling voters for years that ObamaCare has transformed America into a hellish communist nightmare, the ones running for president have to present something that resembles a health care plan. They've always said their goal was to "repeal and replace" the Affordable Care Act, even though they never got very far into the "replace" part; when Donald Trump said he'd replace it with "something terrific," he was offering about as much specificity as most Republicans have to this point.
But this week, two Republican candidates, Scott Walker and Marco Rubio, have presented their plans, and more are sure to come. Walker's comes in the form of a pdf, so you know it's serious, while Rubio's is (so far) just an op-ed in Politico. But both of them hail from another planet, where all the Republican predictions about how awful the ACA would be turned out to be true (unlike this planet, where just about everything Republicans predicted was wrong), and switching to a newer, crueler system would be no problem at all.
There's a lot wrong with both of their ideas, but what's most striking is how they ignore the fact that doing what they propose would be an enormous upheaval in health care, more so than the implementation of the ACA itself was.
Both start by repealing the Affordable Care Act in its entirety, which is what you have to say if you're a Republican, but which is also vastly more complex than they're willing to admit. A sensible Republican might say, "Let's remove provisions A, B, and C, then add provisions X, Y, and Z." The only reason they don't is that they have to bow down at the altar of "repeal."
For instance, the ACA made a number of reforms to Medicare, including incentives for providers to move away from a fee-for-service model, which encourages lots of spending, and toward a model that pays them for keeping the patient healthy, reducing hospital readmissions, and so on. Do Republicans dislike this? I've never heard any of them say so — but since it was part of ObamaCare, it has to go.
Which means that all those providers that have spent a couple of years changing how they operate would now have to change back. The millions of people who are now on Medicaid because of the law's expansion of the program would immediately lose their insurance. The millions who got coverage through the health care exchanges would probably also lose their coverage, because the exchanges would cease operating, and the plans that insurance companies designed with the ACA's regulations in mind would likely be eliminated. Those who rely on the ACA's subsidies would, under both Walker and Rubio, get a tax credit — but in many cases one less generous than the subsidy they're getting now, making insurance unaffordable again.
That's not to mention the fact that both would transition Medicare from what it is now — one of the most successful social programs in American history, beloved by its beneficiaries, with an iron-clad guarantee of coverage for all — into a voucher (or "premium support") program, where the government would give seniors some money and they'd do their best to get covered by private insurers, with no guarantee they could get coverage or that they could afford it.
Which leads me to my favorite line in Walker's plan: "Unlike the disruption caused by ObamaCare, my plan would allow for a smooth, easy transition into a better health care system." Piece of cake! I'd just toss tens of millions of people off their current insurance, eliminate the health care exchanges, roll back a whole series of payment reforms in Medicare that are already changing the way doctors and hospitals operate (for the better), force young people off their parents' policies, and completely transform Medicare for the worse. It'll be smooth and easy.
Walker and Rubio's plans contain some things that are perfectly fine (like wellness programs), a bunch of terrible zombie right-wing ideas (like limiting people's ability to sue for medical malpractice), and things that have been proven to fail (like high-risk pools for people with pre-existing conditions). They also have provisions that could dramatically increase costs for consumers, like Rubio's plan to wind down the tax deductibility of employer-sponsored insurance. But more than anything else, they're hampered by their refusal to deal with the world as it is right now.
In the Republican fantasy world, the rate of uninsured hasn't fallen dramatically (it has), the cost of the ACA is outrageous (it is projected to cost far less than originally thought), everyone who got insurance through an exchange hates their coverage (those people are actually more likely to be satisfied than people with employer-based plans), the ACA caused premiums and health care spending to skyrocket (just the opposite has occurred on both counts), and the law ground job creation to a halt (job creation has been excellent since the law took effect).
If Republicans could accept that reality, they'd be able to say, "OK, but this law still has some problems, so let's figure out how to fix them." If they said that, they'd get agreement from the other side, because there are no Democrats who would deny that the ACA can be improved. But that's not possible, because Republicans have convinced themselves that improving the law is tantamount to collaboration with the enemy. Instead, it's better to cry "Repeal!" and stage another 50 failed congressional votes to do so.
This is the place the candidates' health care plans come from. I suspect they know what they're offering is a joke. But now if anyone asks they can say they have a "plan." Just don't bother asking what would happen if it were to actually be implemented.