Health care “repeal and reform” is a mess, and both parties must share the responsibility for what now appears to be a national crisis.
It’s worth recalling the essential elements of the Affordable Care Act – Obamacare – that have led to the crisis.
The ACA extended health insurance coverage to tens of millions of people who could not be assured of decent medical care because they couldn’t pay for it. They would be required to buy insurance in the marketplace, but would receive financial help to pay for it.
Obviously, expanding coverage with government financial help requires more public funds, so the ACA provided for tax increases on the wealthiest individuals and on employers providing luxury, “Cadillac” insurance plans.
If people did not have employer-provided plans, they would turn to state market places in which insurers would compete for their business. However, there could be no public, nonprofit option available as a competitor and a backstop, because congressional Republicans blocked it.
The ACA worked, but not entirely well. Millions more gained coverage. But some states, like Maine, refused federal aid to extend low-income coverage. Costs rose because of uncertainty in Washington about federal funding. Some insurers dropped out of state markets. The wealthy fretted.
President Obama did a poor job selling a major new policy, and the GOP attacked it successfully, gaining control of Congress. Then, more than 50 times, it voted outright repeal of the ACA without an alternative, knowing that Obama could prevent their gesture from ever becoming law.
Finally, Republicans gained control of both houses of Congress and the presidency. Though President Trump made generous promises about a replacement, he had no proposal, leaving the solution to congressional Republicans who could pass a bill without a single Democratic vote.
As David Brooks, the New York Times columnist wrote, many Republicans ignored conservatism, with which they were identified, for a simple solution: reduce the number of people covered and the coverage, while eliminating the tax increases supporting the ACA.
This approach is consistent with a broader GOP policy that calls for reducing the size of government and cutting taxes. Reducing coverage saves money. It does not matter that millions would lose or be denied health insurance and find themselves forced back into emergency rooms for their care.
Part of their “repeal and replace” policy would allow younger people with fewer health problems not to purchase coverage, reducing the insurance pool supporting the costs of older citizens.
These reforms would all take place by modifying, but not repealing, the ACA. Hard-line conservatives thought they did not go far enough and opposed the proposed changes. Moderate Republicans thought they cut off too many people and they, too, opposed the proposed changes.
Result? No bill that can command the nearly unanimous Republican support required.
Meanwhile, conservative institutions have come up with reform proposals. They start by accepting that all people should have insurance coverage. They suggest reducing costs by lowering the income cap for Medicaid eligibility, cutting any federal subsidy for help above that level.
People should be allowed to use their health savings accounts to buy prepaid care, under which a medical procedure would be priced as a whole instead of by each provider in the process. And the “Cadillac” tax on luxury plans would remain.
Congress would also lift its prohibition on Medicare conducting competitive bidding for drugs. That would save the program billions that could support health coverage.
The conservative view is that reforms need to be made that can survive a change in political control in Washington. Otherwise, if the voters don’t like the GOP “reforms,” they will elect Democrats to repeal the repeal.
What’s wrong with the Democrats? They are acting just as Republicans did. They have not said a word about the changes to ACA they would propose to fix its problems. They hope to gain support simply by opposing the Republicans.
The obvious leader should be Barack Obama, who should lead in developing ACA improvements instead of washing his hands of Washington. A former president, even one with a namesake program, staying in the fray is unusual, but Trump proves these are unusual times. Other Democrats could accept his leadership, because they know he can’t run again.
Nothing can be expected from the White House that simply wants to take credit for whatever is passed. Everybody needs to accept almost universal coverage, but there should be Republican and Democratic alternatives from which both sides could negotiate.
The risk of failure not only threatens the health care system, but government itself.