Alan Zendell, March 26, 2017

Donald Trump and Paul Ryan say they’re done with health care for the foreseeable future. That’s an interesting choice of words, because the last few weeks have proved that they’re not very good at foreseeing anything. They’re now on record predicting that Obamacare will implode and die, and that the country will blame the Democrats. What both predictions tell us is that they care more about political bickering than providing health care for people of limited means.

They said it loud and clear with the failed AHCA, and they’re re-affirming it by asserting that they can’t improve the system unless they destroy it first. All the pretense on the campaign trail about their concern for working class Americans is revealed for what it is, a cynical refusal to put their money where their mouths are.

The only argument they have that makes a shred of sense is that the maligned Obamacare mandate forces people to buy insurance at the market price and penalizes them if they don’t. But they never discuss why the mandate exists. They’re counting on two things, that most Americans won’t remember the eighteen-month-long debate that preceded the passage of the Affordable Care Act in 2009-10, and few if any really understand the issues.

No one wanted the mandate; it was a terrible idea. But when the issue of single payer coverage, or anything that even smelled like it was overwhelmingly rejected, there was no other way the ACA had chance of succeeding actuarially. So once again, let’s strip away all the obfuscation and focus on reality.  “Single payer” is code for the federal government, and the powerful lobbies representing the wealth of the far right don’t want the government to accept responsibility for providing affordable health care. That would be incredibly costly, and it could only be paid for by increasing taxes and/or cutting defense spending. Don’t let anyone convince you that it’s more complicated than that.

Moreover, the ACA could be fixed and the mandate eliminated but for those Republicans who will only accept a solution that humiliates President Obama by erasing his signature achievement. The principal thing wrong with the ACA is the lack of regulatory control of how much insurance companies can charge for coverage. But that would be a form of price controls, and there’s nothing Republicans hate more, though most public utilities have been tightly regulated for decades without bringing down our republic.

Now that Americans have been tantalized by the prospect of affordable health care, they’re not going to let the issue die. The longer this fight goes on, the more voters will direct their anger at the far right as it becomes apparent that they are the only political entity that is seriously opposed to it. It’s a fight that groups like the Freedom Caucus must ultimately lose.

I understand why Americans mistrust the creation of a new federal bureaucracy which would, in effect, expand Medicare to cover everyone. As much as I believe in universal health care, I shudder at the thought of leaving it entirely in government hands. But maybe there’s another way.

Suppose insurance companies had an incentive to provide affordable coverage that limited their risk of financial loss. Suppose we required every health insurer to offer its own version of universal coverage and let it compete for business in the marketplace. The government will always have to provide some form of subsidy for low income people – it already does in the form of Medicaid and dozens of state-only programs.

Suppose, in addition, that Congress created a fund that could be used to reduce the risk for insurers who were willing to gamble on affordable care and realize huge losses as a result. Those companies could apply to an impartial government commission for partial reimbursement of their losses. That may sound radical, but it’s not very different from the way most state insurance commissions operate now when they approve premium increases.

The result would be a system in which everyone shared the risk without taking control of the program away from the private sector. It still wouldn’t be cheap, but the same ultra-conservatives who wish to scuttle the ACA have always touted competition in the marketplace as the best way to reduce costs. Doesn’t it seem reasonable that a Congress that cared about keeping its promise would at least give ideas like this a shot, instead of watching millions of people lose coverage, just so they could blame the opposition party?

No one thought there was sufficient voter antipathy with the system to elect Donald Trump president. Wait until the voters direct their anger where it should be, at Congress.