One of America’s top conservative columnists, Ross Douthat of the New York Times, has grudgingly come to terms with the painful fact that “no politically realistic alternative” to Obamacare exists. Douthat laments the failure of Republicans to back House Majority Leader Eric Cantor’s proposal to move $3.6 billion in HHS discretionary funding to pay for high risk pools. It seems the GOP’s free market purists who currently enjoy veto power within their party oppose any health care reform that implicitly recognizes the legitimacy of the Affordable Care Act. Douthat elaborates:

…You can’t actually have a conservative alternative to Obamacare if you can’t recognize that “managing” the health care system requires changing the way it (already, pre-Obama!) subsidizes health care, which in turn requires increasing the subsidies available to at least some people (the sick, and Americans who don’t get insurance through their employers) even as you reduce them for others (by capping the deduction for health insurance, as a first step). It’s true that this kind of change is a “big government program” relative to the libertarian utopia, but relative to the status quo it’s nothing of the sort, and anyway I don’t see many Republican congressmen casting bold votes to actually eliminate the health-insurance tax exclusion. Instead, they’re happy to just pretend that the existing system represents some sort of free-market ideal in order to score points against the new health care law and avoid taking on any policy risk themselves — and then happy, as in this case, to demagogue as “big government” any constructive steps toward a world that’s actually more consonant with free market principles than the status quo.
This, this, is the Republican Party’s health care problem. It isn’t that conservative ideas about health policy don’t exist, and it isn’t that they won’t work. It’s that right now the feasibility question is purely academic, because even after five years of debating these issues, and despite Eric Cantor’s best efforts, there still aren’t enough Republican lawmakers willing to take even the smallest of steps toward putting those ideas to the test. This means that no matter how much of a “bureaucratic nightmare” the implementation of the current health care law turns out to be, liberals at least have this ace in the hole: When it comes to health care reform, there is still no politically realistic alternative to their approach.

Douthat is dancing around the painful fact that the GOP really has one big idea for health care reform, dog-eat-dog deregulation and elimination of all government involvement. All of the other tweaks proposed by Cantor and other Republican realists are relatively small ideas that can’t get any traction in their party, ruled as it is by ideologues.
In a system that links health security to employment, but has no serious commitment to full employment, there will always be the so-called “high-risk pools.” The purist ideologues of the GOP see this group as expendable byproducts of their social Darwinist vision. The irony is that President Obama would welcome Republican tweaks to the ACA; that was the intention from the outset — to establish a framework that could be amended over time to provide universal coverage without destroying the option of private insurance.
It’s beginning to look like the only way the ‘realists’ in the GOP will regain influence in their party is for Republicans to experience a midterm rout of historic proportions in 2014. Democrats should be eager — and ready — to oblige.