How Do Republicans Think about Health Care Reform?

Rep. Paul Ryan is the wonky Republican representative who wants to save American health care by putting health benefits entitlements in a stiff straitjacket. Ezra Klein is a wonky liberal blogger who supports the president's health care plan to extend health care to tens of millions of Americans, even if it increases federal spending by over one hundred billion annually. Their conversation today on Ezra's blog is a wonderful showcase of two extremely smart people who have done their homework and then some of the minutiae of health care reform. It's also a good example of two extremely smart people with ... what's that term? ah yes ... fundamental disagreements about the big ideas in health care reform. This exchange is telling:

Ryan: Look, I believe we need to do health-care reform. And the employer-tax exclusion is the place to go. That is a huge driver of health inflation, no one has the guts to take it on, and what's a crime in my mind is that I think people in the administration would agree with this. I think economists would agree with it. That's where we should go to fund health-care reform. But we're not. Because of politics. And unfortunately, we're creating a fiscal house of cards instead. We're not dealing with the entitlements that are unfunded right now. We're creating a new one.

Klein: But on the exclusion, Max Baucus wanted to fund reform through the exclusion. And the administration, which had attacked John McCain on his attempt to repeal the exclusion, were ready to go with him. They didn't get any Republican support on that, though. If Bob Bennett and four Republicans had come to them and said, look, if you go hard at the exclusion, you have my vote, they could've gone hard at the exclusion.

Ryan: There's a distinction though. The Patient's Choice Act that I have doesn't repeal the exclusion and put the money in a new government spending program. It takes the money and gives it to the individual. There's a very big difference of opinion here. You don't end the exclusion and have the government spend it on a program. You give it to every individual. But the point I'm trying to make is we spend enough on health care. We don't need to do more. We need to do what we do more efficiently and effectively.

This point bears repeating: it doesn't matter that Democrats and Republicans agree about some details in this bill. The overlap is interesting to talk about, but it's peripheral. What matters is that most Democrats want a new government spending program and Republicans don't. In his New Yorker column this week, I think the wonderful Hendrik Hertzberg missteps:

The health-care reform bill--which, despite everything, is still alive--is an ambitious piece of legislation, however modest it may be by the measure of the rest of the developed world. Ideologically and substantively, it is centrist. It has Republicans, and Republicanism, in its family tree. For better or for worse, it's already bipartisan.

So health reform adheres to the Republican platonic ideal, even if no flesh-and-bone Republicans vote for it? Maybe. Or maybe it doesn't adhere to Republicanism at all because it's garnishing a decidedly liberal goal with conservative touches. Maybe saying "it's already bipartisan" is like a steakhouse saying its filet mignon is vegetarian, because it's served with quite a lot of carrots.

Here's the basic logic of health reform to me, if we start with with the premise that insurance must be reformed: the insurance reforms Obama seeks like banning the practice of denying people with preexisting conditions would send premiums through the roof if young healthy Americans knew if they could wait until they got sick to get care. So we need a universal mandate to buy insurance and a penalty for those who don't. But some of the non-insured can't afford coverage on their salary. So we need a robust subsidy package to help them out. But robust subsidies cost tens of billions of dollars we can't make up with Medicare cuts. So we need to find new tax sources. That makes sense to me. But if the idea of a new government program repulses you, then naturally you're going to see any conservative trimmings -- Medicare cuts, and interstate exchanges, and employer benefit taxes, and tort reforms -- as Trojan horses rolling new federal obligations into Washington.

I don't put much stock in a Ryan's consumerist solution to health care reform for the reasons Brookings' Henry Aaron enumerated. But I do think that having an honest debate about health care -- even if it's too late now -- begins with acknowledging fundamental differences between both sides. To end where I began, that's what I found so elucidating about the conclusion of the Ryan-Klein conversation. Sometimes smart honest people just don't agree.