It’s Still a Dog

Back in March, I made some observations about the AHCA, the bill to “repeal and replace” the Affordable Care Act that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill – cynically dubbed the “Better Care Reconciliation Act of 2017” – is no better than what the House threw over the fence.

The bill retains essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.

I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don’t work. The ACA is based on a few interdependent ideas:

  1. For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
  2. To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
  3. To facilitate getting everyone in the risk pool, subsidies are provided to those who can’t afford the premium

Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill does nothing to address the real challenges facing our healthcare system today – access, quality, and affordability. As the President might say: “sad.”

What do you think?

3 thoughts on “It’s Still a Dog

  1. I agree on all points. Several questionable assumptions underlie the Republican position. (I am tempted to place the words “Republican” and “position” in separate quotations, because the current administration is surely not Republican in any ordinary sense, nor is their position on healthcare a “position” in the sense of representing a reasoned approach to public policy. Instead, it appears to illustrate an anti-Obama spinal reflex.)

    In any case, the first, very questionable assumption is that healthcare can be made to operate like a free market. There is scant empiric evidence to support this position and decades of run-away cost to support the opposite view. Second, political double-think obviously underlies the acceptance of Medicare as a necessary and effective (governmental) payment mechanism while Medicaid expansion and subsidized insurance are attacked as “socialist.” Finally, it is counter-factual to assume that money will be saved from the macro-system by defunding care for the underserved.

    True, a shorter lifespan for the poor will “reduce the excess population” in the Dickensian sense, but significant cost-shifting to the hospitals that inherit the uninsured, with their under-managed diabetes, heart failure and COPD, will, one way or another, be passed along to society as a whole. And of course the question remains: is this the society we want?

    1. Well said! The news out today, that the bill’s consideration is being delayed because John McCain is recovering from surgery points out two more points:
      1. The vote is so precarious that one senator’s absence can make the difference
      2. the deep irony that the vote is delayed because one citizen is availing himself of care that will be denied to millions if this bill passes

    2. I whole-heartedly agree with Dr. Nash’s post and Dr. Grosso’s comments. I think the foundation for the Republicans’ unpopular health care plan and their eventual failure to enact legislation, despite controlling both houses of Congress and the Presidency, can be traced to a time before Donald Trump had even risen to TV infamy on the Apprentice. While Bill (and Hillary) Clinton attempted to craft health care overhaul at the start of his first term, a few Republican senators came up with their own ideas. The HEART bill featured numerous familiar proposals, including an individual mandate, insurance vouchers for the impoverished, and a ban on denial of insurance to people with preexisting conditions. Make no mistake, this had significant differences from the ACA (for example, no Medicaid expansion or increased taxes on the wealthy), but it did enjoy sponsorship from almost 20 Republicans (including current Iowa senator Chuck Grassley). Sadly, congress was unable to reach any significant compromise and healthcare reform was tabled for more than a decade.

      Fast forward to the ACA debate in 2009, which initially featured bipartisan committees to discuss healthcare reform (including Senator Grassley on one of them). While it seemed progress could be possible, Senate Minority Leader Mitch McConnell declared that no Republican would support the legislation. Some of this objection was surely rooted in policy differences (like tax increases), but the main goal was likely, as McConnell once stated, to make Barack Obama a one term president. McConnell’s decision did two things: first, it allowed Republicans to have a constant foil during campaigns in the proceeding elections and certainly contributed to their string of electoral victories (even if the campaigns were often rooted in disinformation aimed at appealing to voter emotions, like the disseminated lie of “death panels”).

      But the second thing he did was back Republicans into a corner from a policy standpoint. Republicans refused to acknowledge that the ACA was a compromise of some sort. It took some Republican and Democrat ideas, but still had to appeal to moderates in order to reach the 60 vote threshold to avoid a filibuster. After a 7 year crusade against the bill, which included numerous votes to fully repeal it (including from our friend Senator Grassley multiple times!), Republicans are now discovering that legislation more conservative than the ACA cannot succeed. Now that Americans have heard what the BCRA and AHCA would actually bring to their healthcare, the ACA looks better every day; it currently has an all-time high 55% approval rating (only 41% disapprove). In contrast, the BCRA has less than 20% support – in counties that voted for Donald Trump. It is hard to understand what audience would actually support these bills; who is benefiting under this legislation?

      Now that Americans are faced with the prospect of losing healthcare, the outcry against the BCRA and AHCA has been significant. The ACA is mostly working in states where it was implemented in full effect: in states with Democratic governors, less than 2% of the population lives in counties with one or fewer insurers. While Republicans used their campaign against the ACA to win short-term over the past seven years, the irony of their hard-line stance is that we may finally have both parties come to the table to fix healthcare long-term. The ACA (and single-payer healthcare) now looks far more attractive to the general public. There is still a significant amount of work to be done, but hopefully this public defeat will bring some moderate congressmen to the negotiating table to work across the aisle and improve the current system rather than start from scratch.

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