As of March 24, the Republicans cancelled their vote on the repeal of Obamacare, after almost cancelling the vote on the 23rd, in a candy-assed attempt to avoid admitting defeat by having the bill fail passage on the floor. Allegedly the main reason the drama got prolonged another day was because Donald Trump insisted that a vote be held, because that was going to be the last time he would push for a healthcare bill. His idea of pushing apparently included reminding them that leaving Obamacare as-is would mean that Planned Parenthood would still be funded, and threatening Republican congressmen that he would campaign for their primary defeats if they voted against the bill. The fact that his bluff was called indicates he’s not so great at the Art of the Deal. It also indicates that Republican congressmen had more reason to worry about their seats if they DID vote for the bill.
The official name of the Obama Administration plan was the Affordable Care Act, or ACA. The new proposal was officially the American Healthcare Act. As in, “you thought you still had coverage? AHA!” Some wags have also referred to this as Trumpcare, deliberately reminding Republicans how they loved to brand the ACA as Obamacare. The difference being that Obama in the wisdom of time came to accept that label, whereas, Trump, who would put his name on 99-cent condoms if somebody paid him a lot of money for the privilege, refuses to have his name associated with the Republican plan. So in honor of House Speaker Paul Ryan, some critics were calling AHA “Ryan Care.” Or even blending Trump and Ryan to create “Tryan Care.” Pronounced, “try and care.”
There were many issues with the new plan, to the extent that it actually existed. Not only did hardcore conservatives wish to destroy requirements for “essential” coverage for women’s healthcare (not just abortion), but the plan was touted as saving money by making subsidies dependent on age rather than income such that it would create an “age tax” on older working adults while younger taxpayers would be incentivized to get health insurance by greater subsidies. This naturally caused a lot of liberal objections. But then it’s not like they weren’t going to object anyway. Complaining that the new bill shifted the benefits from older and poorer Americans (who create a loss to the system) to younger, well-off Americans (who are better able to pay for the insurance market) sort of assumes that that isn’t the point, or indeed that there isn’t a virtue to having a system that pays for itself better than the ACA does. The problem is that not covering those who can’t afford care defeats the purpose of “the Affordable Care Act.”
This ultimately reveals the whole problem with the use of the insurance industry as the paradigm for coverage. For one, there’s a difference between health insurance and insurance for other services. When you get an auto insurance policy, for instance, you aren’t expecting to get into a car accident that week. When you get a life insurance policy, you aren’t expecting to die next week. (And if you are, the company may be investigating your insurance risk.) Insurance is exactly that: coverage in a matter of last resort, not a basic support where you are expecting to collect on the policy immediately. Whereas for people with chronic conditions (like type II diabetes, for example), you get an insurance policy on the expectation of “collecting” on it immediately. And that’s because in this country, costs of medical care are such that for all practical purposes, health insurance is how you GET medical coverage.
But this still means that medical care is covered through the private insurance market. And insurance companies survive and profit through what’s called a “risk pool.” Basically a company selling life insurance, for instance, has a majority of its policyholders continuing to make payments for the duration of the time that they do not need to collect on their policies (in this case, until death). This works because the majority of people paying into the system do not die shortly after taking out the policy. The risk pool is big enough to cover the risks of collection. But if a majority of people with health insurance plans had to collect because of expensive and chronic conditions, the companies could not continue to profit and survive. So of course they were going to decide that “pre-existing conditions” were a barrier to getting coverage, and of course they were going to conjure rationales against anybody collecting on a policy once one actually needed to do so. So you had Obamacare. But in order for Obamacare/the ACA to cover everybody without the “pre-existing condition” barrier, you had to make the risk pool nationwide, which is why the hated individual mandate (forcing you to get coverage or face a tax penalty) is baked in. If the government forces insurance companies to take all patients and does not force those who do not currently need coverage to get it, no one would be covering the expenses of those at-risk people.
But all that just reveals the ultimate problems with the ACA. It does do one of the two things we needed a healthcare reform to do: It eliminated “pre-existing conditions.” But to do so it mandated coverage without sufficiently subsidizing the costs to the consumer, who was forced to take out a service with no regard for economic conditions, which defeated the other purpose of the Affordable Care Act- making healthcare affordable. But that was because the system is built around the private insurance industry, whose economic model is based on NOT providing a necessary service in order to profit.
The difference is that the ACA doesn’t cover people because it doesn’t render healthcare affordable, while AHA doesn’t cover people because it elides the difference between theoretical “access” to care and practical availability of care to the average income level. As one pundit put it, we all have access to Ferraris, but how many of us own them?
Even beyond that, if we had the dream of many liberals – single-payer, or Medicare for all- we would run into the limitations of the current system. The real reason healthcare is unaffordable, even with (or arguably because of) insurance, is because costs are out of control. Having government cover those costs would simply mean that they get transferred from the private sector to the government, and when government runs a deficit, that has effects on the private sector.
You have that situation because unlike most countries that have single-payer (the rest of the First World, really) we don’t put cost limits on what medical providers and drug companies can charge for covered services.
For instance, when Medicare was given a prescription drug benefit (Part D) via the Medicare Modernization Act in 2004, the Act specifically forbade Medicare from negotiating bulk prescription prices, as opposed to the Veterans’ Administration, which is able to do so, and whose patients pay far less for drugs. The MMA was largely written by Rep. Billy Tauzin (R.- Louisiana), who resigned from Congress on February 2004, the same month the legislation was passed. The year afterward, once he was legally able to do so, Tauzin became head of the Pharmaceutical Research and Manufacturers of America.
So if you’re a senior citizen and you want to know why your drug coverage has a “donut hole”… that’s why.
In my Internet discussions, I eventually got converted into advocating for single-payer, and I did so on fiscal conservative grounds: It is illogical that the US, of all the developed nations, pays more for healthcare and gets worse results. But again, simply changing the system to a public one will not necessarily work if we do not correct the real problem with the system, which is that American medicine is predicated around a bureaucracy in which the government caters to industry interests more than the consumer.
It’s for these reasons that a lot of providers not only rejected Obamacare but the insurance system altogether. This is referred to as cash-only or direct primary care. Another reason that some doctors took this path is that costs actually decrease due to the reduced overhead for not having to do billing and coding through insurance companies. This also means there is more price transparency, which makes it easier for consumers (patients) to determine costs. There is of course still going to be an out-of-pocket issue, which is part of why insurance companies cover health care in the first place. But as we have seen, the current system is often counterproductive for the purpose of getting medical care at affordable cost, and without transparency, there is not even as much concern for the Law of Supply and Demand as there would be normally in the medical system. Reform should thus focus on the “demand” (consumer) end instead of the provider, otherwise a public system would suffer the same long-term problem as the current public-private hodgepodge we have, where the costs are so high that neither government nor employers can sustain them without increasing liability.
If conservatives and libertarians had been bitching about Obamacare for more than six years, you would think that they would mull all this over and come up with some concrete proposals to transition away from Obamacare, as opposed to what we got, which was the Republican Party acting like the kid who partied until 3 am the night before a test and suddenly realized he had to do homework.
But that just leads to the political issue. For all the public attention paid to the dysfunction of Donald Trump, he is a reflection of the Republican Party that nominated and elected him. Their relationship is a quid pro quo: They let him get away with what he wants so that he could give them what they want- a signature on items like an Obamacare repeal that they say they’ve wanted since 2010, and had always been shot down before now by Obama’s veto. The problem was that Republicans were free to “repeal” Obamacare all they wanted with no consequences because they knew there would be that veto. But now that they allegedly have everything they want, the problem is that any bill they agree to would be passed by this president – and they would have to deal with the consequences of that.
It’s almost as if the Republican Party was simply a grievance industry that survives on stoking public hatred and resentment, and cannot even try to formulate constructive policy, let alone attempt to implement it, because if they did, they would lose their reason for existence.
And if Republican congressmen were willing to call Trump’s bluff on policy, is it possible that their voter base may call their bluff in turn?