Douthat Proposes "Modify Modestly" As an Alternative to "Repeal and Replace"

Ross Douthat urges that conservatives try to take a more constructive tack on modifying the Affordable Care Act than the current mantra of repeal it or defund it:

To address the first problem, Republicans should work to deregulate the new health care exchanges, so that high-deductible, catastrophic coverage can be purchased as easily as comprehensive plans. To address the second, they should propose capping the subsidies for the uninsured, so that they don't dramatically exceed the value of the existing tax subsidy for employer-provided insurance.

The mandate is a harder puzzle, since it works in tandem with the requirement — popular enough to have many Republican supporters — that insurers cease denying coverage to customers with pre-existing conditions. If you repealed the mandate without repealing that requirement, people could simply wait until they were sick to buy insurance, driving everyone's prices up.

But Republicans could propose dealing with the same problem in a less coercive way. [...]

I'd certainly hope to see this as the future of the health care debate. The Douthat approach starts from the premise that the goal of universal subsidized regulated private health insurance is legitimate. And it agrees that to get there you need what the ACA offers, namely a solution to the problem of adverse selection, a regulatory definition of "health insurance," and taxpayer financed subsidies to make it affordable to everyone. If you assume a world in which this ACA tripod is generally accepted, political disagreement then takes the form of one side wants to get ambitious with the definition of "insurance" even though this means more expensive subsidies and another side wants to restrict the cost of subsidies even though this means accepting a more modest definition of insurance.

The upshot of that wouldn't be my health care utopia, or even a policy I'm totally thrilled with, but I think it would be a decent outcome and it would be one in which universal coverage and the basic framework of the Affordable Care Act becomes entrenched. And this, or something like it, is the ultimate outcome of health care policy debates in most countries. Obviously left-wing and right-wing parties disagree about tax rates and spending levels, but they generally work inside a common framework.