The way forward for health care

When two more Republicans Senators announced their opposition to their party’s legislation to repeal and replace the Affordable Care Act, effectively dooming its chances, President Donald Trump had a quick answer, tweeting that Republicans should repeal now and come up with a replacement later. But the shelf life of that idea was barely 12 hours; three moderate senators quickly quashed the plan, for an excellent reason: if the GOP thinks their current overhaul of the nation’s health care system is problematic and deeply unpopular, that idea would be infinitely worse.

The Republican opposition to the Better Health Care Reconciliation Act (the official Senate name for Trumpcare) came from both ends of the GOP spectrum, with conservatives upset that it doesn’t go far enough in lowering costs for healthy consumers (which is to say, it doesn’t sufficiently unravel Obamacare’s requirements that health insurance plans actually cover the services people might need when they become sick) and moderates worried that it would kick too many of their constituents off Medicaid. A repeal and delay plan wouldn’t solve either problem and could potentially exacerbate them.

Bowing to that reality, President Trump has offered up yet another idea via tweet: “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan. Stay tuned!” He expanded on the idea in an appearance at the White House, saying that if the ACA fails, “Democrats are going to come to us” to work on an alternative because “I’m not going to own it. I can tell you the Republicans are not going to own it.”

Nothing could be further from the truth. President Barack Obama and the Democrats wouldn’t get the blame if the health care marketplace collapsed at a time when they control the White House and both chambers of Congress. The people in power would, and deservedly so, because the ACA isn’t collapsing. It’s being killed.

While the Senate health bill was collapsing in Washington on Monday, officials at the Maryland insurance administration were hearing arguments from two health insurers for why their rates on the Obamacare insurance exchange should increase by 25.1 percent, in the case of Kaiser Health Plan of the Mid-Atlantic, or 65 percent, in the case of Evergreen Health. The reason was not that the Affordable Care Act was fatally flawed, as President Trump and Republicans in Congress argue, it’s that the GOP has made sure it was never allowed to work as intended and has added massive uncertainty to the market by pursuing a repeal. “Letting Obamacare die,” as President Trump suggests, promises more of the same.

Obamacare’s prohibition on denying coverage for those with pre-existing conditions, its elimination of lifetime limits on benefits and other protections designed to fix some of the worst failings of our old health care system created a policy problem known as “adverse selection,” that is, older and sicker people who couldn’t get insurance before would be the most likely to enter the marketplace. The ACA had several interlocking provisions to deal with that, all of which have been undermined to some degree by Republicans obsessed with erasing the law. The individual mandate — a requirement that all consumers buy insurance — was never backed by a sufficient penalty to persuade enough younger and healthier consumers to obtain coverage, and the Trump administration has further muddied the waters by accepting tax returns from people who don’t answer the question about whether they have insurance. The ACA included a mechanism called “risk corridor” payments to protect insurers against the unpredictability of costs in the new marketplace. It was designed to compensate those whose customers turned out to be sicker than expected, but Congress never appropriated funds for the purpose, so insurers were being paid about 13 percent of what they were due. Finally, because the ACA limits out of pocket expenses for consumers, the legislation also calls for payments from the government to insurers to help recoup those costs. Although the Trump administration has grudgingly continued them, the uncertainty about their future has promoted insurers to drop out of markets or request large rate increases.

An official policy of malign neglect, as the president is now suggesting, would make all those problems worse and lead to even greater rate increases or market collapses than conservative opponents of the Senate health care bill are complaining about now. If President Trump is serious about “letting Obamacare die,” that means stopping enforcement of the individual mandate altogether, which would make problems in individual markets far worse.It would mean ending risk corridor and cost sharing reduction payments, sending insurance rates through the roof.

Meanwhile, “letting Obamacare die” would do nothing to alleviate the concerns of Republican moderates that thousands of their constituents are at risk of being kicked off Medicaid. Given how adamant conservatives are about rolling back not only the Medicaid expansion but the core program itself, the only way a Republican moderate could in good conscience sustain the president’s strategy is by assuming that Democrats will take control of one or both houses of Congress in the next election.

President Trump is complaining that Democrats are obstructing health care legislation, tweeting an apparent call to end the Senate filibuster rule — “8 Dems control Senate. Crazy!”, though what difference that would make is unclear, given that Republicans can’t even get to 51 votes in the Senate. But it’s not as if Democrats have been rejecting the opportunity to work on health care. They have been completely shut out of the drafting of the bill — as have, for that matter, most Republicans.

Sen. John McCain, recovering from emergency surgery that would have bankrupted most uninsured families, issued a statement Monday night calling for the Senate to return to “regular order,” that is, to stop trying to pass a bill under special rules that allow a straight majority to prevail and instead “hold hearings, receive input from members of both parties, and heed the recommendations of our nation's governors so that we can produce a bill that finally provides Americans with access to quality and affordable health care.”

If Congress did that, it would discover that the contours of debate about ACA replacement plans so far have been false. There isn’t really a massive divide about whether to preserve the Medicaid expansion but rather a solid consensus to do so, including governors, senators and representatives of both parties. There isn’t a great clamor to repeal the tax increases on high earners that help pay for the ACA. Key conservative groups that once drove the Obamacare repeal effort have been focused on the prospect of a broader tax overhaul instead.

The Koch-funded Americans for Prosperity, for example, mustered one tweet Monday reiterating that “we haven’t given up in our battle to fully repeal Obamacare,” but otherwise, it has been focusing on tax reform, union rules and net neutrality. In fact, the ACA is now enjoying majority support for the first time, with approval ratings twice as high as those for the Republican replacement efforts.

Some influential conservative groups are greeting the Senate bill’s collapse warmly, arguing that it didn’t achieve the grassroots goal of obliterating Obamacare entirely. But the reality is that unless Republicans want to see 23 million fewer people with health insurance at the end of a decade (House bill), or 22 million (Senate bill) or 30 million-plus (straight repeal with no replacement), they need to work within the basic structure of Obamacare.

There’s plenty of room in the political center to work out an improved ACA 2.0. It starts with guaranteeing cost-sharing reduction payments and enforcement of the individual mandate (initially a Republican idea, by the way) to shore up the insurance markets. It includes reforms to encourage lower prescription drug prices and state-level reinsurance programs to help offset the cost of older, sicker consumers — an idea that has gained traction among some Republicans. Some of the health policy experimentation allowed under the ACA has been notably successful in holding down the growth in health care spending — Maryland’s updated Medicare waiver being a prime example. Congress could work on prodding more states to move away from a fee-for-service model to one that focuses on value. Ohio Gov. John Kasich, a Republican, articulated many of those ideas in a New York Times op-ed proposing a centrist approach to fixing the Obamacare exchanges and reforming Medicaid.

Like it or not, many core Republican voters, the very people who helped propel Mr. Trump to the White House, stand to lose the most if Obamacare is killed outright or through gradual sabotage. And it’s not at all clear that what would come next would be a Republican-friendly replacement. A Pew survey last month found that 60 percent of Americans believe it’s the federal government’s responsibility to ensure that everyone has health coverage, with 33 percent supporting a single-payer approach — up five points since January.

During the campaign, President Trump promised better insurance that covers more at lower cost, but it’s abundantly clear that neither he nor his party’s leaders in Congress have any ideas for how to accomplish that. Democrats do and would be happy to provide them, if Republicans would only ask. With the GOP caucus irreconcilably split, that is the only way forward.

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