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After doing Talmudic-like studies of the doctrines on health reform promulgated by Republican health-policy makers and the conservative economists who inspired them during the past two decades, I am devastated to discover that all of those studies have been for naught. We are now told, sometimes by the same prophets of yore, that these doctrines were not only wrong, but outright heretical, which in this context means un-American.

New doctrines are rumored to be in the making, but the first word on them has yet to be committed to new, sacred tablets, mainly because there have not yet emerged any new ideas worth committing to tablets.

Do not take my word for it. Newt Gingrich, one of the Grand Old Party’s aging prophets, said so himself in his recent speech to the Republican National Committee.

Comes now conservative commentator John R. Graham of the Pacific Research Institute, telling us that Republicans seem lost in the desert even in their hit-and-run insurgency against their sworn enemy, the Affordable Care Act of 2010 (ACA).

What is a befuddled immigrant to the United States like me, eagerly trying to become a right thinking American, to make of it all?

My early introduction to the texts coming from conservative thinking on health reform was the Heritage Plan of 1989, Viewed through the prism of the ACA of 2010, its language seems eerily familiar. One provision, for example, proposed a:

“[m]andate all households to obtain adequate insurance. Many states now require passengers in automobiles to wear seatbelts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement” (p.5).

The Heritage Plan also called for income-related, refundable tax credits toward the purchase of private health insurance. Although it did not call for community rated premiums, it proposed means-tested public subsidies and toward high out-of-pocket expenses of individuals and families. It did not spell out the daunting administrative apparatus that would entail. But one can imagine the required new bureaucratic apparatus, replete with auditors to prevent fraud and abuse. Presumably, income-related subsidies would have involved the Internal Revenue Service (IRS) in some ways as well.

Next came a text put forth by conservative economist Mark V. Pauly and like-minded colleagues in Health Affairs. It is worth a reading again. Here’s the core of these prophets’ proposal:

“In our scheme, every person would be required to obtain basic coverage, through either an individual or a family insurance plan. …All basic plans would be required to cover specified health services; plans could, however, offer more generous benefits or supplemental policies. The maximum out-of-pocket expense (stop-loss) permitted would be geared to income, with more complete coverage required for lower-income people, to ensure that no one faced the risk of out-of-pocket expenses that were catastrophic, given their income.” Again, lots of government intrusion into health care, along with links to the IRS.

There then followed a real life health bill based on these ideas, the late Republican John Chafee’s antidote to the emerging Clinton plan. It was called the “Health Equity and Access Reform Today Act of 1993” and had an impressively long list of Republican co-sponsors, among them Senator’s Orrin Hatch (R-Utah) and Charles Grassley (R-Iowa), now fierce opponents of the ACA. As the folks at the Kaiser Family Foundation have shown, many of its provisions of Chafee’s bill have a striking similarity to provisions in the ACA of 2010 and comparing.



I know from personal conversations with former Congressman Bill Thomas (R-California) that in the late 1990s he and his colleague James McCrery (R-Louisiana), both of the House Ways and Means Committee, had crafted in the late 1990s a bill encouraging the gradual replacement of employment-based health insurance with individually purchased insurance. Apparently it could not be sold to the incoming Bush Administration, probably because it called for a slew of new regulations of the health insurance industry and the bill called for more federal money than the much smaller amounts that Bush Administration was willing to spend on expanding health insurance. Although a copy of the draft bill is not publicly available, I would bet that it continued the design parameters typically proposed by Republicans in the 1990s and incorporated in the ACA of 2010.

As late as 2003, Stuart Butler of the Heritage Foundation testified before Congress on health reform. In it he noted that

“Today there is a legal and moral obligation on society to provide some level of health care to those who become ill,” adding “It is also reasonable to expect residents of the society who can do so to contribute an appropriate amount to their own health care. This translates into a requirement on individuals to enroll themselves and their dependents in at least a basic health plan — one that at the minimum should protect the rest of society from large and unexpected medical costs incurred by the family. And as any social contract, there would also be an obligation on society. To the extent that the family cannot reasonably afford reasonable basic coverage, the rest of society, via government, should take responsibility for financing that minimum coverage.”

Finally, as late as May 2009 Republican Senator Tom Coburn (R-Oklahoma), a physician, threw into the legislative hopper Senate Bill S.1099, “The Patient’s Choice Act”. It had seven Republican co-sponsors. Evidently it was hastily composed, presumably as an antidote to the then brewing ACA as a platform from which Republicans could negotiate with Democrats.

Coburn’s bill calls for a benefit package like that given to Members of Congress, state-based health insurance exchanges based on some European models (Switzerland and the Netherlands), auto-enrollment into health plans with a chance to opt out, guaranteed issue, and so forth (see Expanded Summary of the bill here and here). I had commented on that bill in The New York Times in 2010, noting how the bill slouched towards the Affordable Care Act. The insurance exchanges called for in S.1099 all would have to have interfaced with the IRS, with the state Medicaid plans, and with employers – certainly small employers – just as do the exchanges under the ACA –roughly the same bureaucratic infrastructure.

So what are we to make of the spectacle of Republican anti-Obamacare insurgents, busily fielding hit-and-run attacks against sections of the very sacred tracts that their own prophets had promulgated as principles during the past 20 years? On what principles, new or old, are these hit-and-run raids conducted?

The amazing spectacle put on by this insurgency, however, can explain why Republicans now come across as nomadic tribe lost in the intellectual desert on this issue, as is being argued by Newt Gingrich, and also why now even their hit-and-run raids pick on the wrong targets, as John Graham argues. It seems that, like most insurgencies, this one knows what it is against but not what it stands for.

But history tells us that there is always hope. Eons ago the twelve tribes of Israel, under the leadership of Moses, reportedly were lost in the Sinai desert, in a random walkabout of some 40 years. A possibly apocryphal rumor has it that eventually an exasperated Mrs. Moses stamped her besandaled foot in the sand and shouted “I have had it with your leadership, Moses! I’m going to ask for directions.” And so she did, and so they got to the promised land.

Perhaps some day someone in the Republican Party will ask for coherent, principled directions on health policy – and this time follow these directions. Perhaps.

Uwe Reinhardt is recognized as one of the nation’s leading authorities on health care economics and the James Madison Professor of Political Economy at Princeton University. He is a regular contributor to The New York Times Economix Blog.