Paul Krugman: Republicans Have No Ideas at All

We'll find out soon enough if Republicans are craven enough to sell out their constituents' health care in the name of tax cuts for the rich. What we do know is that they're every bit as terrible at governance as they are effective at obstruction. As Paul Krugman writes in his Monday column, one reason they can't come up with a credible alternative to Obamacare is that, "You can't change any element of the Affordable Care Act without destroying the whole thing." 


The ACA is incrementalist by nature, an acknowledgement that many Americans enjoy their employer-provided insurance and that the insurance industry, with all its lobbying clout, would not allow a single-payer system. To provide better plans at a lower cost to more people, it offers a three-legged stool approach. The first leg, Krugman explains, requires "insurers offer the same plans, at the same prices, to everyone, regardless of medical history." This addresses the problem of pre-existing condidtions, arguably the most-beloved part of legislation, even if Republicans want the public to believe its "death spiral" is imminent.

Without additional legs, they'd be right: "Healthy people would wait until they got sick to sign up, so those who did sign up would be relatively unhealthy, driving up premiums, which would in turn drive out more healthy people, and so on." The solution was a much less popular leg of the stool, the individual mandate, which Krugman explains is, "a requirement that people sign up for insurance, even if they’re currently healthy. And the insurance must meet minimum standards: Buying a cheap policy that barely covers anything is functionally the same as not buying insurance at all." 

For those who can't afford the individual mandate, the government provides sudsidies. Americans at the very bottom of the economic ladder receive a 100 percent subsidy in the form of Medicaid. This constitutes the third leg of the stool.

It's a delicate balance, and one that requires extensive cooperation from state governments. According to Krugman, "where states have in fact cooperated, expanding Medicaid, operating their own insurance exchanges, and promoting both enrollment and competition among insurers, it has worked pretty darn well."

But red-state governments have proven largely uncooperative, refusing Medicaid expansions, de-incentivizing competition among insurers, eliminating the individual mandate, and generally cutting off any leg of the stool they can.

Now Republicans are trying to do the same at a national level. Take, for example, Ted Cruz and his Cruz Amendment, which would allow insurers to offer skeleton plans with minimal coverage and sky-high deductibles. That's fatal to people with pre-existing conditions, effectively cutting off the most popular leg of the ACA and pushing the sickest Americans into the most expensive insurance market.  

"Obamacare," Krugman reminds us, is "a well-thought-out law that works where states want it to work." Sure, it should be made to work better and more effectively, but Republicans are hell-bent on killing it. It's a tragedy for Americans that they don't have anything in its place. 

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