If the Republicans in Congress want to try again to pass a health care bill, maybe they should make it about health care.
Three Republican efforts to repeal the Affordable Care Act failed spectacularly this year — including the latest, the Cassidy-Graham bill — because they weren’t really about health care. They were about money. Sure, the two are inextricably linked, but if your goal is to slash federal spending so you can cut taxes, then label your bill the Great American Tax Cut Act and promote it that way. Apparently there are enough smart voters to tell it’s a sham when you label something a “health care” bill but what you really do is eliminate care in order to save money.
Democrats made one giant mistake when they passed the Affordable Care Act, aka Obamacare, in 2010: They hurt some people in order to help others. The law helped millions of low-income Americans who couldn’t otherwise afford health insurance get it. But Obamacare punished middle-income Americans — especially those between the age of 50 and 64 — who bought individual policies and earned too much to qualify for subsidies under the ACA. Their premiums skyrocketed and some had their plans canceled, because they didn’t comply with new ACA rules. President Barack Obama earned the Politifact Lie of the Year award in 2013 for his claim that “if you like your health care plan, you can keep it.”
The competition for future Lies of the Year would have been intense had any one of the three GOP health care bills passed this year. Their backers claimed the bills would push health care costs down, improve coverage for people covered under Obamacare today and create more efficiency. But the main goal of each bill was to drastically cut federal spending on Medicaid, the health program for the poor. Obamacare expanded Medicaid, and the GOP scheme was to roll back that expansion, and go further.
Under each of the three bills, the number of uninsured would have soared, with estimates ranging from 22 million to 32 million addition people lacking coverage during the next decade. By definition, that is not health care reform.
Learning from Obamacare
The lesson of Obamacare was the old medical oath: First, do no harm. So if the GOP ever produces an actual health care bill, its first aim should be to keep coverage levels where they are, at a minimum. Its second aim should be lowering costs for everybody, including those covered by government plans and those covered by private-sector plans. Getting costs under control would by its very nature help more people afford health care coverage, and lessen the burden on taxpayers who support Medicaid and other federal health programs.
Tackling the chronic rise of medical costs in the United States won’t be easy, but it’s not impossible, either, and plenty of smart reformers have ideas. The government could come up with new ways to incentivize private-sector providers to lower costs, giving the free market a nudge to do what it’s best at. Providers should be rewarded, for instance, for offering the best care at the lowest price instead of offering the most care, regardless of outcome. This requires much better ways of measuring quality and long-term results. But isn’t this the kind of thing Silicon Valley is supposed to excel at? Isn’t artificial intelligence about to provide the ability to do remarkable new things? Isn’t there an app for that?
Universal health care
The United States also ought to be moving toward universal health care coverage, which would have economic benefits and is the modern standard in every other advanced nation. Universal coverage doesn’t mean a single-payer system dominated by the government, which frankly doesn’t seem plausible in the United States any time soon. Instead, we could get there by relying more or less on the system we have now — including employer-provided care — while instituting some kind of new government backstop as last-resort catastrophic care for the unfortunates who still lack coverage. No less a conservative stalwart than economist Milton Friedman proposed this in 2001.
Meanwhile, stabilizing the Affordable Care Act would be the responsible thing to do, until Congress comes up with something that is legitimately better. That means enforcing all provisions of the law, committing to all the funding mechanisms and promoting it thoroughly so people know how to sign up. The ACA is far from perfect, but if Republicans abandoned their white-whale obsession with killing it, they could pursue other reforms that would actually help people, and businesses.
Finally, if Republicans are intent on reeling in Medicaid, they should pursue that on its face. Medicaid spending is, in fact, on an unsustainable trajectory, just like Medicare and Social Security. It’s inevitable that at some point, Congress will either have to cut funding for these entitlement programs, or raise taxes to pay for all the benefits that have been promised. So addressing Medicaid spending isn’t inherently evil.
The problem is doing it sneakily, which is what the Republicans have been doing all year, by dressing up sharp Medicaid cuts as the “Better Care Reconciliation Act” and other nonsense. Ya wanna cut Medicaid, guys? Then call it what it is. Meanwhile, it would be nice if you could think about fixing the health care problems we still have, at some point.
