A few weeks ago, Ezra Klein and Ben Domenech had a fairly detailed back-and-forth — culminating in this mano-a-mano exchange — about whether a Republican or conservative alternative to Obamacare actually exists. You can read or watch them go at it and form your own judgment, but I think the answer is pretty straightforward: A conservative alternative or alternatives, yes; an alternative that Republican lawmakers are ready to vote for, no.  That gap between conservative policy wonks and G.O.P. politicians has been with us for some time, but last week supplied a particularly stark reminder of its existence. Nearly all of the plausible conservative blueprints for reform involve increased funding for high-risk pools where people with pre-existing conditions can purchase insurance, as an alternative to regulations requiring that insurers cover all applicants regardless of their health status. These pools exist under Obamacare as well, but they’re purely transitional and deeply underfunded — and this underfunding provided an opportunity that Eric Cantor and the House Republican leadership tried to exploit last week, with a bill that would have shifted $3.6 billion in money that’s basically being used as the Health and Human Services Department’s discretionary fund into the federal high-risk pool instead.  Instead, the bill died because, well, too many House Republicans didn’t want to vote for it. I’ll let Domenech explain the policy and political malpractice at work here (the quote is from his email newsletter, The Transom):  The Cantor-sponsored shift would’ve accomplished a couple of political goals: it would’ve bolstered a high-risk pool based approach to pre-existing conditions, which has generally been favored on the right, and it would’ve hampered Sebelius’s ability to shift dollars around at whim without going back to Congress for approval. As such, it seems a logical move which doesn’t wed Republicans to any long term policy positions regarding Obamacare …  As they tend to do, however, fiscal conservatives split on Cantor effort. It was opposed by the Heritage Foundation, the Club for Growth, and “Tea Party leader” Brent Bozell. Redstate announced it would be scoring the vote … They described the step, in insulting fashion to anyone who understands the policy involved, as an Obamacare “fix” …  This type of strategic idiocy has been the mark of conservatives throughout the process of Obamacare’s passage and implementation, so expecting them to be smarter now is probably too much to ask. Whatever the motives of the conservatives who opposed this measure, they have accomplished the following ultimate goal: they’ve made leadership less likely to take up any possible wedge legislation on implementation; they’ve missed an opportunity to bolster the argument that Republicans care about pre-existing conditions; and, most importantly, they’ve made it easier for Sebelius to implement the law …  So what were opponents thinking? Well, here’s one opponent’s explanation:  “The issue I think many of us are having with this particular piece of legislation … you’re replacing one big government program with another big government program,” said Representative Raul Labrador of Idaho …  … he added: “Subsidizing health care is not what Republicans should be about. Republicans should be about managing health care” to lower costs for Americans.  And therein lies the rub, because you can’t actually have a conservative alternative to Obamacare if you can’t recognize that “managing” the health care system requires changing the way it (already, pre-Obama!) subsidizes health care, which in turn requires increasing the subsidies available to at least some people (the sick, and Americans who don’t get insurance through their employers) even as you reduce them for others (by capping the deduction for health insurance, as a first step). It’s true that this kind of change is a “big government program” relative to the libertarian utopia, but relative to the status quo it’s nothing of the sort, and anyway I don’t see many Republican congressmen casting bold votes to actually eliminate the health-insurance tax exclusion. Instead, they’re happy to just pretend that the existing system represents some sort of free-market ideal in order to score points against the new health care law and avoid taking on any policy risk themselves — and then happy, as in this case, to demagogue as “big government” any constructive steps toward a world that’s actually more consonant with free market principles than the status quo.  This, this, is the Republican Party’s health care problem. It isn’t that conservative ideas about health policy don’t exist, and it isn’t that they won’t work. It’s that right now the feasibility question is purely academic, because even after five years of debating these issues, and despite Eric Cantor’s best efforts, there still aren’t enough Republican lawmakers willing to take even the smallest of steps toward putting those ideas to the test. This means that no matter how much of a “bureaucratic nightmare” the implementation of the current health care law turns out to be, liberals at least have this ace in the hole: When it comes to health care reform, there is still no politically realistic alternative to their approach.
There are conservative ideas on health care, but there aren&#8217;t enough Republicans willing to actually vote for them.