By Jonathan Cohn
St. Martin’s Press, February 2021
Excerpts from the Conclusion – What Change Looks Like:
The next great debate over health care reform might not happen for many years. Or it might happen right away. It depends to some extent on what else is happening in politics – and how the Supreme Court rules on the new Obamacare case. But a debate will happen sooner or later, and when it does, two directions are possible.
One is to reverse course, to scale back the Affordable Care Act or eliminate it altogether. This remains the agenda of the Republicans and their allies. The idea is to cut back on the things conservatives instinctively oppose, so that taxes are lower, regulations are looser, and federal spending comes down. But for many, the objection to Obamacare also reflects a more basic rejection of universal coverage, which by definition means putting everybody into one system with a lot of redistribution – with contributions from healthy people financing the costs of the sick, and the wealthy paying extra to cover the poor.
Republicans want less of that redistribution or maybe none at all. And if they get their way someday, people who are healthy will save money, at least while they remain healthy, and people at higher incomes won’t have to pay so much in taxes. But the burden of medical expenses will shift onto those who have more health problems and those who have less money, which is what every reputable projection about every serious Republican plan of the last ten years has shown.
The alternative approach on health care is to continue the crusade for universal coverage that Democrats have been carrying on since the days of Roosevelt and Truman. It would mean finding some way to make sure everyone has insurance – as in 99 percent of the population, not just 92. It would mean improving benefits, so everyone can afford to go to the doctor, or fill a prescription, or be admitted to the hospital without having to pay big out-of-pocket costs. Today, that’s a problem for many Americans with “good” coverage. Ideally, it would also mean a simpler system, one in which patients and providers weren’t constantly fighting with insurance companies over billing and approvals, or shifting between plans and networks.
The Affordable Care Act, like the Clinton plan before it, was an attempt to achieve the liberal end of universal coverage through a more conservative scheme that relied heavily on competition among private insurers. But the intellectual foundation for that calculation seems increasingly shaky, especially when it comes to controlling the cost of care.
Even many card-carrying economists schooled in the virtues of markets and hazards of government control now wonder whether it’s time for the United States, like other developed nations, to set a global budget for health care, have the government regulate prices, or maybe do both of those things.
The version getting the most attention in American politics today is the single-payer proposal that Bernie Sanders and his followers have been promoting: Medicare for All. The reality is that any system that covers everybody with low out-of-pocket costs and some kind of government control over spending is going to look a lot more like Medicare for All then what the U.S. has now. That shouldn’t scare anybody. Medicare for All is the same basic idea Harry Truman proposed in the 1040s, and it’s in the DNA of Medicare, a program Americans cherish.
The case shouldn’t be that hard to make, given how well the best systems abroad perform. But it will require a lot more work – by wonks and operatives, officials and activists.
By Don McCanne, M.D.
Jonathan Cohn’s new book has been receiving excellent reviews, and rightfully so. It is a well researched, meticulously accurate summary of the last ten years with the Affordable Care Act and the preceding health care reform history leading up to it.
If you are interested in history, it is great, but more importantly, if you are interested in how we got here in health care reform and where the various pathways before us lead, it is essential reading.
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