And yet, somehow, the president-elect’s proposed health care fix has already been a success.
By Reihan Salam
Has Donald Trump spent months
secretly crafting a top-to-bottom transformation of our broken health
system that will patch up America’s scrapes and bruises and straighten
the nation’s teeth? All signs point to no. A week ago, Trump told the Washington Post that he was putting the finishing touches on a new health reform plan that would guarantee “insurance for everybody.”
Alas, he offered no details other than to say that his plan would offer
“much lower deductibles” and that it would be released very soon. In a detailed account
of intra-Republican wrangling over the future of Obamacare, Yuval Levin
reports that “the conservative health-care universe, including some
people on Trump’s own team, quickly concluded that the separate
administration plan he described was entirely a figment of Trump’s
imagination.”
Considering it doesn’t exist, Trump’s imaginary health care proposal
has accomplished a great deal. For one, it has tempered the enthusiasm
of congressional Republicans for unraveling Obamacare too quickly. It’s
reminded them that the road to replacing Obamacare is fraught with peril
for the GOP, and that “insurance for everybody” is a message that
appeals not just to Democrats but to a growing number of Republicans.
First, let’s consider the argument that there is nothing for
Republicans to worry about, and that to delay Obamacare repeal would be
to play into the hands of Democrats. The basic idea here, perfectly
distilled in a recent Wall Street Journal op-ed by Betsy McCaughey, is that Obamacare didn’t really do anything of value, so getting rid of it won’t make much of a difference.
One of the chief political arguments in favor of passing (and now
keeping) Obamacare was that millions of Americans faced the prospect of
being denied insurance coverage because of pre-existing conditions, and
that Obamacare would eliminate that possibility. But according to
McCaughey, having a pre-existing condition was only an issue for
individuals seeking insurance coverage in the individual market. Since
roughly half of Americans (49 percent) are covered by employer-based
insurance and another third are covered by Medicare (20 percent) and
Medicaid (14 percent), pre-existing conditions were irrelevant for most
people. We didn’t need Obamacare to tackle this problem, she insists.
Rather, we needed to establish high-risk pools for the small number of
people who fell through the cracks. McCaughey argues that while
Obamacare premium subsidies will cost $56 billion this year, fully
funded high-risk pools would cost something on the order of $16 to 20
billion. Sounds simple, right? Roll everything back to the pre-Obamacare
status quo, add some high-risk pools, and you’re good to go.
There is a problem with McCaughey’s line of analysis, however. It’s
true that the political case for Obamacare rested in no small part on
the fear that pre-existing conditions would render tens of millions of
people uninsurable. But the deeper problem, then as now, is that half of U.S. adults
have at least one chronic health condition, such as heart disease,
cancer, diabetes, and arthritis, among many others. Most people with
these conditions can’t come close to covering all of the costs
associated with their medical care, which means that other people—family
members, employers, or taxpayers at large—have to cover the rest. Yes,
the pre-existing condition problem is a relatively narrow one that
affects working-age adults who are too young for Medicare, who earn too
much money to qualify for Medicaid, and who don’t receive health
insurance from an employer, as James Capretta and Tom Miller explained
back in 2010. The chronic disease problem, on the other hand, is far
broader and more profound, and Republicans ignore it at their peril.
When families are left to bear the financial burden of chronic
disease, their economic well-being is endangered, as millions of
Americans can tell you based on first-hand experience. As health care
costs for employers rise, an ever-larger share of compensation comes in
the form of health benefits rather than wages, which partly explains why
wage growth has been so sluggish
for middle-income workers. Soaring health costs led many employers to
drop coverage in the pre-Obamacare era, and they’re the reason why at
least some have reduced the work hours of their employees to skirt
Obamacare’s employer mandate. What if we let state governments carry the
load? When that happens—and it is already happening—spending on other
government services, from public education to transportation, gets
crowded out. Unlike the federal government, states are constrained by
the need to balance their budgets, which is why they’re left to beg for
federal bailouts when the economy takes a dive and tax revenues plummet.
One way or another, and whether we like it or not, voters are going
to look to the federal government to do something about the cost of
chronic conditions. So does that mean Republicans should give up on
moving beyond Obamacare? Not at all. But they need to accept that the
federal government will always be the payer of last resort for the
chronically ill.
There is at least one Republican who understands this instinctively. In his 2000 manifesto The America We Deserve, Donald Trump offered the following riff on universal coverage, which Avik Roy recently quoted on his blog:
I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. We must not allow citizens with medical problems to go untreated because of financial problems or red tape. … Working out detailed plans will take time. But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal healthcare.
If Trump did have a plan that would offer “insurance for
everybody,” what might it look like? It’s hard to say. My suggestion is
that he declare an Obamacare truce:
Keep the Obamacare exchanges as a safety net for those who need
comprehensive coverage and can’t afford it without premium subsidies,
but also tweak the law to allow the young and healthy to buy cheap
non-Obamacare-compliant plans if they’re willing to go without
subsidies. But as I’ve written,
it’s not really Trump’s job to come up with detailed policy proposals.
His job is to hector Congress into doing his bidding, and shilling for
an imaginary health care plan was as good a way as any to get real
policy ideas rolling in. Trump is saying, essentially: This is what I
want, this is what the American people want, now go figure out a way to
do it, and if you don’t, I’m going to call you horrible names on
Twitter.
slate
slate
No comments:
Post a Comment