Krugman: The balloon, the box and health care

Imagine a man who for some reason is determined to stuff a balloon into a box - a box that, aside from being the wrong shape, just isn't big enough. He starts working at one corner, pushing the balloon into position. But then he realizes that the air he's squeezed out at one end has caused the balloon to expand elsewhere. So he tries at the opposite corner, but this undoes his original work.

If he's stupid or obsessive enough, he can spend a long time at this exercise, trying it from various different angles, and maybe even briefly convince himself that he's making progress. But he's kidding himself: No matter what he does, the balloon isn't going to fit in that box.

Now you understand what's happening to Republican efforts to repeal and replace the Affordable Care Act.

Republicans have spent many years denouncing Obamacare as a terrible, horrible, no-good law and insisting that they can do much better. They successfully convinced many voters that they could preserve the good stuff - the dramatic expansion of coverage that has brought the percentage of Americans without health insurance to a record low - while reducing premiums, shrinking deductibles and, of course, doing away with the taxes on high incomes that pay for the program.

Those promises basically define the box into which they're trying to stuff health care.

But health care costs money. In particular, if you want to make care available to Americans who have pre-existing medical conditions - including the condition of being not rich and being relatively old, but not yet eligible for Medicare - you have to find some way to subsidize them.

Obamacare provides those subsidies in part with direct public funding, in part with regulations that implicitly use premiums paid by the healthy to cover the cost of caring for the less healthy.

There are other possible ways to achieve the same goal, but the money has to come from somewhere. That basically says how much air there is in the balloon - and it makes the balloon too big for the box.

Now you understand why there's a predictable, repetitive rhythm to the health care story.

Again and again, we read news reports to the effect that Republicans are closing in on a plan that will break the political deadlock. They'll repeal the Obamacare taxes and block-grant Medicaid! No, they'll make insurance cheaper by eliminating the coverage requirements! Or, the latest idea being floated, they'll let insurance companies raise premiums on people with pre-existing conditions and compensate by creating special high-risk pools!

And each time the plan turns out to have a fatal flaw. Millions will lose coverage; or they'll keep coverage, but it will become so threadbare it's almost worthless; or premiums will skyrocket for the most needy unless vast sums - hundreds of billions of dollars - are devoted to those high-risk pools.

The important thing to remember is that these problems don't keep popping up because the people devising the plans are careless, and keep forgetting crucial issues. They're popping up because the GOP is trying to stuff a big balloon into a small box, and every time you squeeze it somewhere it inflates someplace else.

And because the task Republicans have set for themselves is basically impossible, their ongoing debacle over health care isn't about political tactics or leadership. Even if Donald Trump were the great deal maker he claims to be, or Paul Ryan the policy wonk he poses as, this thing just can't work.

The only way Republicans might have been able to do what they promised would be if they had some way to make health care much cheaper. That would in effect let some air out of the balloon, and maybe make it possible to get it into the box after all. But they don't.

The truth is that while Republicans have portrayed Obamacare as a crazy, inefficient scheme, it has in fact been much more successful at containing costs than even its proponents expected.

There are some things we could do that would probably make it even cheaper, but they would all involve moving left - say, introducing a public option, or going all the way to single-payer. The GOP, which is determined to move right instead, reducing the public sector's role, has offered no reason for anyone to believe that it could do better.

All of this raises the obvious question: If Republicans never had a plausible alternative to Obamacare, if this debacle was so inevitable, what was the constant refrain of “repeal and replace” all about?

The answer, surely, is that it began as a cynical ploy; at first, the Republicans hoped to kill health reform before it really got started. And now they've trapped themselves: They can't admit that they have no ideas without, in effect, admitting that they were lying all along.

And the result is that they just keep trying to stuff the balloon into that box.

Paul Krugman is a columnist for the New York Times.