July 4th, 2020


Bush offers a real health-care replacement

Ramesh Ponnuru

By Ramesh Ponnuru

Published Oct. 14, 2015

Jeb Bush's new health-care plan looks a lot like the plan Scott Walker embraced two months ago, which in turn looks a lot like the one Marco Rubio sketched in an op-ed article and the one touted by Sens. Orrin Hatch and Richard Burr and Rep. Fred Upton.

That's good. It means Republicans are finally reaching a consensus on what to do about health policy that draws on the best conservative thinking on the subject. Bush - for whose campaign my wife works -- is helping to ratify that consensus.

All these plans aim to change federal tax, spending and regulatory policy to enable almost everyone to get insurance that covers, at a minimum, catastrophic health expenses. People who don't have access to employer-provided plans would receive a tax credit that they could use to buy coverage -- and that coverage would no longer have to comply with all the mandates in President Barack Obama's Affordable Care Act. In Bush's version of the plan, older people would get a larger credit. The tax break for employer-provided coverage, meanwhile, would be capped, both to keep the tax code from rewarding the most expensive plans and to raise some of the money needed for the credits.

People with pre-existing conditions would be protected by a regulation that requires insurers to offer coverage on the same terms to sick people and healthy people, so long as they had maintained coverage. That proviso is there to keep people from waiting until they're sick to get insurance. Meeting that condition would be easier than it has been in the past, thanks to the tax credit.

Bush would also reform federal aid to state health-care programs for poor people, to give them much more flexibility. States could, for example, pass along much of their funding to the recipients so that they could purchase private coverage.

Not all Republicans have accepted this consensus. Louisiana Gov. Bobby Jindal, for example, agrees that Republicans need a plan to replace the health-care plan and thinks it should involve changing the way the tax code treats health insurance. But he disagrees with the other Republicans on two points. He would offer a tax deduction, not a credit, which would save the federal government money but enable far fewer people to buy insurance. And he would let people who have access to employer plans use the credit to leave those plans for the individual market -- a step that would run the risk of destabilizing the employer market.

Jindal denounces plans that offer a tax credit as a betrayal of conservatism, although he backed them before running for president. Most Republicans who have taken up the issue, however, have concluded that a viable replacement for the health-care plan has to largely leave employer coverage alone and enable people who now get coverage through the health-care plan to buy new plans.

The trade-offs in this sort of proposal depend a lot on the details, and Bush is not yet saying how large his tax credits would be. If he ends up in the same ballpark as other plans, a lot of middle-class families would get larger tax credits than the health-care plan gives them. But the near-elderly, in particular, would get smaller ones.

If Republicans run on this sort of plan -- whether with Bush as the nominee, or someone else -- they'll be able to say that they'd cover almost as many people as the health-care plan does for less money, and without ordering people to buy insurance. That insurance won't cover everything that Obamacare-compliant policies cover, but in many cases it will offer more protection against catastrophic expenses. Republicans would also be able to say that they offer something to the poor: health coverage that's better than Medicaid.

Before the health-care plan, tax policy favored those who had expensive employer-provided coverage but offered little help for middle-class people who weren't so fortunate. During the debate over the health-care plan, congressional Republicans put forward a bill that left that policy alone and thus wouldn't have done much to expand coverage. Mitt Romney ran against Obama in 2012 promising to replace the Affordable Care Act, but was fuzzy about what he'd replace it with.

Bush and an increasing number of other Republicans are offering voters something better. The lack of a Republican alternative on health care, and especially of an alternative that would enable almost everyone to get coverage, has been the great Democratic talking point in this debate. It's one they may soon have to retire.


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Ramesh Ponnuru has covered national politics and public policy for 18 years. He is an author and Bloomberg View columnist.