The Republicans’ campaign promises are coming back to haunt them as they confront the reality of dealing with a law that is supported by at least half of the population. The debate among Republicans in Congress over how to deal with the GOP’s promise to repeal and replace the Affordable Care Act (ACA) is splitting the party. While there is consensus to repeal it at the earliest possible time, there is great concern that the political fallout of doing so without an acceptable replacement plan will lead to dire political consequences. Whatever the GOP does, or does not do, Democrats can rightly claim that the Republicans will own the results as “Trump Care,” and pay for it in the 2018 and 2020 election cycles.
Although there is not yet a firm GOP replacement plan, it is likely to include replacement of the ACA’s tax subsidies with tax credits, shift more costs to patients, remove the individual mandate, limit annual caps, permit skimpier insurance plans, and shift responsibility to the states through block grants for decisions about health care coverage.(1) Other likely components of the GOP plan will be expansion of health savings accounts, selling insurance across state lines, expansion of high-risk pools (all of which have largely failed in recent years), and further privatization of Medicare and Medicaid.
Outright full repeal of the ACA would eliminate two of the most popular parts of the ACA: the requirement that insurers cannot deny coverage based on pre-existing conditions and allowing children to be covered on their parents’ coverage until age 26. That may call for follow-up legislation addressing these needs. The Centers for Medicaid & Medicaid Services (CMS) are giving Republicans a gift by their new proposed rule for 2018 giving states more authority to determine level of coverage, set rules for adequacy of networks, and change enrollment procedures, all of which benefit insurers more than patients. (2)
The downsides of outright repeal of the ACA are obvious: throwing some 20 million people off of health insurance, and easing constraints on insurers who will charge what the market will bear, reduce coverage and choice through tighter networks, issue more barebones policies, avoid sicker enrollees, and further withdraw from unprofitable markets. All of the GOP plans will shift more responsibility to the states for Medicaid with less funding and whatever exchange offerings may remain on the individual market.
In order to come up with a sustainable health care plan that meets the needs of Americans for affordable and accessible health care, we need to learn from experience and evidence from the past. While the ACA brought improved access for 20 million people, especially through expansion of Medicaid, it has failed to rein in costs after seven years and there is no cost containment in sight. The problems, of course, go back more than two decades before the ACA, including the failure of the insurance market, the lack of enough competition, and segmentation of risk pools to the benefit of insurers. Private insurers are starting to admit that they are on a death march without continued and more generous public funding.
We have learned that privatization results in less efficiency, higher overhead, profiteering, and worse care, whether privatization of Medicare or Medicaid. Further deregulation of health care will just add to our problems. Legislators are being held hostage to the insurance and drug industries as lobbyists win the day within the Beltway and in state capitols.
We have to ask who the health care system is for—patients and families or corporate interests that feed off the backs of sick people and taxpayer money. If the GOP pursues its claimed conservative principles, such as maximizing efficiency and choice, enhancing value, lowering costs, and reining in excess bureaucracy, another alternative is in plain sight, which supports these principles—single-payer national health insurance (NHI). Enactment of NHI would bring universal access to health care for all 320 million Americans in a sustainable way with these benefits:
This is a pivotal time for both political parties and the country, with far-reaching consequences into the future. Any GOP replacement or repair plan will fail, be unsustainable, and incur huge and unaffordable costs for taxpayers without the benefits that Americans need and deserve. The winners would be the private insurance industry, the drug industry, other corporate stakeholders in the medical industrial complex, and Wall Street. The losers would be patients and their families, who will have less access, choice, and affordable care, and face worse health outcomes. States would gain authority but lose by massive cuts in federal funding for health care. In the long run, the Republican Party will be a loser in future election cycles as they face a huge public backlash over their “reform” plan.
The first political party to enact NHI will govern for many years to come. It is an open question which party will realize that first.
Adapted in part from my forthcoming book, Crisis in U.S. Healthcare: Corporate Power vs. the Common Good, to be released by Copernicus Healthcare on March 15, 2017. (5)
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans
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