The good news is that the first rank-and-file Republican healthcare plan of the Obamacare era doesn't reflect a total state of denial. Its conservative authors -- Sens. Tom Coburn, R-Okla., Orrin Hatch, R-Utah, and Richard Burr, R-N.C. -- don't pretend that they can repeal Obamacare and replace it entirely with conservative pabulum like tort reform and deregulation.
Conservative pabulum comprises major parts, but not all, of the new plan. The rest of it is somewhat realistic insofar as it reflects a recognition that fixing the pre-Obamacare status quo requires raising some taxes and spending some money. Coburn, et al., propose to raise the taxes and spend the money in a more regressive, less generous way than Obamacare does, and would require major cuts to Medicaid, but at least we've escaped the fantastical realm of a great deal of earlier Republican thinking.
But it's not nearly good enough. If Republicans had offered this plan as an opening bid in 2009, they might have found Democrats willing to make a counteroffer and negotiate toward some kind of compromise -- or they might have knocked the whole legislative process off the rails. But in 2014, a plan that devolves crucial aspects of Obamacare without any inducement for Democrats is a joke.
It's also kind of a mess.
For instance, step one is to repeal Obamacare, which will instantly muck up the individual insurance market, creating the kind of disruption Republicans have spent the last four months politicking against. Step two is to replace the ACA's coverage guarantee with a less-generous system of subsidies and a "continuous coverage" provision, which will protect people with preexisting medical conditions from discrimination so long as their existing coverage doesn't lapse for more than very brief periods over time. For people without insurance, or who lose their insurance because of the Obamacare repeal, the plan envisions a one-time open-enrollment period during which this kind of discrimination would be prohibited.
The idea is to induce everyone without coverage to enroll all at once, using the threat of future underwriting to motivate the healthy as well as the sick. But the incentive will be much stronger for people who are already sick. And once the enrollment period closes, anyone who missed the deadline or couldn't afford a plan or commits the grievous sin of losing coverage briefly would be consigned to pre-Obamacare purgatory until such time as they qualify for a different system.
And if for some reason healthcare costs start rising rapidly again, we'll be talking about a lot of people. The subsidies are pegged to inflation plus 1 percent, which means they'll get less and less generous over time if healthcare inflation spikes and remains high. If that happens, either more and more people will find coverage unaffordable, or the quality of the plans will deteriorate until they hardly serve the function of insurance at all. In that sense the plan is potentially a stalking horse for an eventual regression to the total nonsense Republicans supported before Obamacare benefits kicked in. I'm going to go way out on a limb and predict that this bill will attract zero Democratic co-sponsors.
These Republicans have recognized that Obamacare has permanently altered the healthcare debate, but they haven't accepted that the new reality is centered around an iron-clad healthcare guarantee. Until they do there just isn't that much to talk about.
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