As Americans rallied across the country this weekend to support the Affordable Care Act against Republicans' efforts to repeal the law that has extended health insurance coverage to 20 million people, President-elect Donald Trump let slip some heartening news in an interview with the Washington Post. Not only would his secret plan to replace Obamacare include "insurance for everybody" even "if you can't pay for it," it would also involve "lower numbers, much lower deductibles" and be "much less expensive." And Americans are not just going to be covered, they'll be "beautifully covered."
That's a big contrast with what Republicans in Congress have been up to. Last week, they passed legislation to repeal most of the law, an effort that would, the Congressional Budget Office reported this morning, result in 18 million people losing coverage in the first year and a doubling of health insurance premiums over the next decade. In short, it would make things worse than they were before the ACA.
Then, about 16 percent of the population lacked health insurance. Policies for individuals or small businesses were often prohibitively expensive, and benefits for those who had coverage were problematic. Insurance companies could refuse to sell policies to people with pre-existing health problems, and they could limit benefits for those who became sick, leaving even those with coverage at risk for financial ruin.
There were a couple of ways to solve those problems. One is to provide health insurance through the government in a single-payer system like the one in Canada and many other industrialized countries. That spreads the cost of paying for the sick across the largest possible risk pool, but it has also long been considered a political non-starter — certainly for Republicans but also for many Democrats. It would be guaranteed to meet Mr. Trump's goal of ensuring that everyone has coverage, but he says that's not what he has in mind.
Another method for expanding coverage and eliminating some of the problems of the old insurance system was to use a combination of subsidies and mandates to bring more people into the risk pool — particularly young and healthy ones — thereby making coverage for older or sicker people affordable without bankrupting the insurance companies. That, plus an expansion of Medicaid to cover those truly too poor to afford even subsidized insurance, is in a nutshell what Obamacare does. Unlike Mr. Trump's mystery plan, it doesn't cover everyone, but it has reduced the uninsured rate to below 9 percent. To actually achieve Mr. Trump's goal of universal coverage would require much tougher mandates than the fines under the ACA and much more generous subsidies, and unless he is completely breaking with all Republican political orthodoxy, we doubt that's what he has in mind.
What we suspect is going on here is actually a bit of a bait-and-switch. Most Republicans in Congress who have been formulating ACA replacement plans state as a goal "universal access" to coverage rather than actual universal coverage. That's a big difference. They offer up a combination of reforms like allowing insurance companies to sell policies across state lines (an idea that hasn't taken root in the few states that now allow it) and expanded health savings accounts, which disproportionately benefit wealthier individuals. Mr. Trump did also throw in the mix the idea that the federal government should negotiate with drug companies over the prices Medicare and Medicaid pay for prescription drugs — a policy Democrats have been advocating for years. Mr. Trump evidently has in mind not a formal bargaining session but a campaign of Twitter shame like his criticism of the costs of the F-35 fighter. That, apparently, is also his strategy for getting Congress to go along with whatever health care reform he proposes.
The Affordable Care Act isn't perfect. In certain respects, it hasn't worked out as intended — in no small part because of Republicans' refusal to fund it adequately. But it remains the most coherent way to expand coverage within the basic confines of America's existing health insurance system while also addressing some of its most egregious failings. In the meantime, it supported innovations in the delivery and financing of health care — notably including Maryland's updated waiver from typical Medicare rules — that have contributed to the slowest growth in American health care spending in memory. It has expanded health insurance to 20 million people and brought the uninsured rate to its lowest level in American history.
Let us join President Barack Obama in saying that if Mr. Trump can achieve all that — if he can ensure that as many people or more have coverage as they do under the ACA, maintain key protections against exclusions because of pre-existing conditions or lifetime coverage caps, and reduce costs to consumers and the government — we'll be first in line to support it and offer our congratulations. Please excuse us while we hold our breath.