April 26, 2017

R.I.P. American Health Care Act

President Trump’s second major initiative, his attempt to replace Obamacare with Trumpcare (a.k.a, the American Health Care Act) has crashed and burned. The disaster was even more dramatic than his failure to implement a Muslim travel ban, which, after all, though on life support, is not definitively dead. Alas, Trumpcare may not be definitively dead, either, as Vice President Pence is trying to sweet talk the Freedom Caucus into supporting a nastier bill that the one that went down in flames.

Now, between fights over health care, seems a good time to offer some thoughts on health care in general and on health care legislation.

Is Health Care a Right?

Liberals argue that health care is (or should be) a right. Conservatives contend that people should be held responsible for their own health care and that having it provided through the government breeds dependency and self-indulgence.

The Declaration of Independence asserts that among the “unalienable Rights” to be secured by government are “Life, Liberty and the pursuit of Happiness.” Without life, however, other rights and privileges are illusory. People who cannot afford health insurance—and even many who can—cannot be guaranteed the medical care required to keep them alive. Regrettably, medical bills are the leading cause of personal bankruptcy in the United States. Even with insurance, a person can be one accident or one infection away from a totally ruined life. Most people, however responsible, cannot protect themselves from every medical catastrophe. Ruined lives hurt the economy and any sense we might have of being a compassionate society.

Virtually all developed countries save the United States have decided that the right to life entails the right to health care.

How We Organize Health Care

Most people of working age get health insurance through their employers. It is individual employers who determine what sort of coverage is available to their employees at a reasonable cost. Why? There are historical reasons for the system, but they have nothing to do with health insurance being inherently connected to employment. Unemployed need health insurance, too. This senseless system has had unintended consequences, at least as far a public policy is concerned. It has kept people in jobs to maintain their health insurance even when the employee could be more profitably employed elsewhere. The ACA has helped mitigate this problem, but, of course, the GOP wants to get rid of it.

Private health insurance companies; for-profit hospitals, labs, and imaging centers; rapacious pharmaceutical companies, and the whole fee-for-service system all help to drive health care costs higher. This is where the real savings are to be had. These sacred cows need to be taken on. The ACA did not do it, and nothing the Republicans will propose will do it either.

The Republicans Fail

For seven years, the GOP railed against the ACA. Candidate Trump spoke about repeal as soon as he got into office. Undoing Obama’s premier legislative accomplishment had virtually become the defining feature of Republicanism. And yet, when the GOP found itself in control of both houses of Congress, as well as the White House, it was obvious that Republicans had no real plan to effect their number one goal. President Trump had promised to repeal and replace Obamacare with something great, but it was clear that he had no idea what that great something should be. Moreover, it quickly became clear that a legislative “victory” on the health care front was more important to him than keeping his promises regarding retaining the parts of the ACA that were universally valued. He therefore farmed out creating legislation to Speaker of the House Paul Ryan, someone who didn’t care about Trump’s promises and who hated the ACA, taxes, and federal deficits.

The Ryan bill was created in secret with no Democratic input and minimal input from House Republicans. What emerged was a bill that jettisoned the most important objective of the ACA—substantially decreasing the number of Americans without health insurance—and adopted what seems to be the Republicans favorite, but unacknowledged goal, namely, providing tax cuts for the rich.

Alas, the Ryan bill, the American Health Care Act, was insufficiently meanspirited for the members of the Freedom Caucus, the outgrowth of the Tea Party. The Freedom Caucus simply wanted Obamacare gone. Attempts to mollify these extremists were not very successful and alienated non-crazy Republicans. In the end, the bill was pulled. At first, it seemed as though Trump and Ryan were ready to leave the ACA in place, letting (self-inflicted) wounds heal and giving time to craft a better-thought-out bill. It now appears that the Republicans will try to replace Obamacare sooner, rather than later.

The Danger Ahead

At the outset of the Obama administration, Republican leaders vowed to oppose the new president at every turn. They did so with great success, culminating in the blocking of Obama’s final appointment to the Supreme Court. Democrats tried valiantly—and foolishly, it turned out—to sweeten the ACA to attract Republican votes. Even though the basic outlines of the law were based on the plan implemented by Republicans in Massachusetts, congressional Republicans would not go along. Moreover, they and their allies whipped up opposition to Obamacare by lying about it. People were concerned that it would destroy Medicare, that their fate would be decided by death panels, and so forth. Countering the lies failed to move public opinion among Republican loyalists, and the belief that Obamacare must go became an article of faith disconnected from any objective analysis. Adherents to the faith increasingly elected like-minded people to serve in the Congress.

As the Trump administration was moving toward repealing Obamacare and replacing it with a program that would hurt more Americans than it helped, public opinion began moving in favor of keeping and perhaps improving the ACA. House Republicans failed to notice; their faith remained intact. They acted—and are acting—like Lucy in the strip below. When circumstances change or more information comes to light, old assumptions not explicitly contradicted tend to be retained, however outrageous that may seem.

Peanuts strip from November 18, 1960

As time passes, more Americans are concluding that the ACA may have more virtues than problems. Obamacare, it turns out, actually has helped millions of people. The next time Republicans try their repeal-and-replace trick. public opinion will be even more opposed to what Republican want to do. Rumors suggest that the next bill will be more draconian than the American Health Care Act. These trends almost certainly doom GOP plans, which will put yet another blot on Trump’s already tarnished escutcheon.

If Republicans truly want to change health care in this country, they just may have to work with Democrats. Democrats will not agree to tossing the ACA overboard, but they would certainly be willing to improve it. Unfortunately for Paul Ryan, any bipartisan bill will not lower government spending or give tax breaks to the rich. It might, however, improve President Trump’s reputation.

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