Sunday, January 22, 2017

Health Care in Society and the Demise of Obamacare

The Affordable Care Act is due to disappear. The incoming administration and Congress are working on making it so. This is the culmination of a long dream of politicians and pundits on the conservative side of the political spectrum. Now, they'll get their wish.

But what is it a wish for? Is it really a wish for wasteful, costly health care with millions of Americans uninsured? Do Republicans really want to go back to a time when people showed up in the ER for routine care, and then stuck the hospital with the bill? Are they aiming for a return to medical bankruptcies? I doubt it.

The ACA was a compromise among the many, moneyed, players in health care: hospitals, pharmaceutical manufacturers, insurance companies, and doctors. Smaller--and less well-heeled--players also participated to some extent: citizens, nurses, consumer advocates, and social welfare organizations such as churches did have their voices heard. The product was the ACA, a law which essentially reformed the insurance marketplace, and a law which gave every player something they wanted, and also placed demands on every player. It wasn't perfect, but it was a step.

The Republican Party and groups of conservative citizens fought it from the moment it passed. "Obamacare" became a slur, like "communism", despite the fact that the ACA was a market-based solution to our insurance market problem, and despite the fact that the major elements of it were essentially based on a policy solution originally proposed by the conservative Heritage Foundation.

Now this is my blog, so in addition to sharing evidence and facts, I also get to share my opinion. I argue that there were two main reasons the ACA became a focus of Republican and conservative rancor. In the former case, the Republican Party, it was pure politics. First, I think it galled the party that Democrats managed to do their thing--create a market-based solution to a social and economic problem, a solution that had the potential to be popular (think: keeping your kids on your policy until they're 26, getting insurance coverage for pre-existing medical conditions).

Second, Republicans saw a political opportunity, and this is related to the latter case, "conservatives". Here I'm talking about less politically-connected, ordinary folks with a particular political point of view. The "tea party" types who saw the ACA as a government intrusion, who saw it as an erosion of their freedom to go without insurance, I guess. Fact is, I have more respect for these folks. I don't agree with them. I think that as our society evolves it is inevitable that we'll have to trade some of our "old rights" for new ones. But hey, I get it. It's a political philosophy, a point of view.

My view is that Republicans saw this disaffected minority (and they have been a minority) as a potential addition to their voting base, a way to seize control of hundreds of local congressional districts. That's just cynical, and I hold them in the lowest esteem for it. If Obama and the Democrats had somehow managed to pass a law greatly expanding Medicare--a "public option" for everyone--and Republicans wanted a market-based solution instead, they'd have a case. But this? This was just political calculation.

Criticisms of Obamacare abound, but what's not much talked about is that any massive legislative act has to be amended and tweaked to work. Unintended consequences happen. This law could have--should have--been adjusted several times in the 6 years since it passed. Republicans, having taken control of the House of Representatives in 2010, could have worked to make that happen. They didn't, because they saw more political opportunity in just obstructing change.

Now, they have their wish, and their "replacement" solutions are sounding either weak or complicated or both. The fact that they need a replacement highlights just how popular the ACA is, now that some 20 million more people have coverage. It's hard to believe that navigating health care insurance could get more complicated, but House Speaker Paul Ryan's current sketch of a plan promises to be just that.

Really? They think that's what Americans want? To have to phone 3 hospitals to see who has the cheapest appendectomy? Changing doctors every year, because every year you have to be on the internet looking for a cheaper option than you currently have? Look, I get the whole "smaller government" thing, but I have to wonder at what point does ardent political philosophy fail the practicality test?

I'm not at all certain about what will happen. Obama was smart. His namesake health care reform isn't perfect, but it showed a large fraction of the voting public a glimpse of a better life. That's not going quietly. Now that Republicans have control, what will they do? Maybe they'll just fix what's wrong with it and give it a new name, like "Patriot Care" or maybe name it after that new president-guy. The essentials will persist but they can take their claim to it, which will make them feel better about their brand.

Or maybe not.

Americans are going through a trial right now. We're arguing with one another about what post-frontier America looks like. This trial began in the turn of the 19th to the 20th century: unions, communism, socialism, environmentalism, the Great Depression, Social Security, Medicare and Medicaid were all being fought over as we left behind the Old World order and tried to figure out what sort of New World order would be fitting for America. Something consonant with our culture but oriented to the challenges of a very different world. Where is that balance?

For about the last 20 years there's been this see-saw between one view of our future and another. Neither is perfect, but both reflect the aspirations of ordinary people, even if those aspirations often get hijacked by politically cynical agents of vested interests.

My view is that health care is a right, and it's a right that materially contributes to both the health of our people and the health of our economy. I know others disagree (but the facts argue in my favor--a blog for another day perhaps). I believe that we all must accept that we can't have (and really don't need) everything we think we do. Some call this rationing, but I just call it rational health care. A relief valve in the form of a free, side market could co-exist, but there's no evidence it would detract from a robust public or hybrid public/non-profit health care system. There's no evidence this would necessarily dumb-down our medical research enterprise--although it might rectify the imbalances imposed by the profiteering which is a troubling feature of our current system (see my blog post from 8/29/16).

Over the coming weeks and months we'll see how Washington's new political leaders tackle this issue. They have to do something, because promises were made, no matter how empty or pointless those promises seem now. Having failed for 6 years to work with the previous leadership on revising Obamacare, Republicans now have to deliver something.

Let's hope it's an improvement.

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