Yep, Health Care Is Complicated

Yes, Mr. President, health care is complicated.

So glad you now understand this. But, um, within 24 hours of acknowledging that complexity, you made a speech to Congress that backtracked.

Namely, you once again said ACA repeal and replace legislation would “expand choice, increase access, lower costs, and at the same time provide better healthcare” even as you referred to Republican ideas and proposals that would, in fact, not easily achieve any of those goals, according to independent analyses.

You also said: “The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we will do.”

An achievement devoutly to be wished—if by lowering health care prices and costs. If achieved by making insurance skimpier or through even higher deductibles and co-pays, not so good.

The Congressional Budget Office and millions of consumers will be paying close attention to that, believe me.

Speaking of the CBO, we hear this week that Republicans in the House now have an updated version of the draft repeal and replace bill leaked last week, and that they may vote on it next week in committee without obtaining a CBO score. And so far, that bill is under wraps, apparently to prevent further leaks as it gets finalized.

(See here for a mostly impartial analysis of the initially leaked draft.)

Moving forward without a CBO evaluation is not a good idea. It’s asking for trouble down the road. And it’s not like other economists and budget experts aren’t going to take a very close look when the bill is made public.

If the next iteration of the bill is anything close to the leaked draft, I’d wager that CBO and others will not be favorable to it on financing, federal budget impact, family affordability, or maintenance of current levels of coverage.


On the good side, you promised a “stable transition” from Obamacare, kicking the big changes to 2018, 2019 or beyond. The draft bill does this, too. The need for a stable transition and preserving the coverage gained by 20 million Americans under Obamacare has garnered significant traction in recent weeks—in part, due to protests at congressional town hall meetings around the country.

In addition, you reiterated your intent not to mess with Medicare and Social Security.

It seems, from press reports, that Jared and Ivanka and even Steve Bannon recognize the political disaster that would result if millions of people lose coverage or if Paul Ryan and the conservative House Republicans got their way on Medicare. (Medicaid, too, as many Republican governors and you also seem to be realizing.)

Thus, as predicted months ago by both Democrat and Republican health policy wonks, the Affordable Care Act did indeed create a new structure and standard for expanded coverage that you and Republicans will have to maintain in large part, even if you never admit the progress therein and continue to vilify the law.

By the way, if you want to build bridges to Democrats to get something passed in the Senate with bipartisan support, I suggest you stop vilifying the law. That worked for on the campaign trail. It’s unnecessary and counterproductive now.

The new wrinkle you brought to the table in recent days is a reprise of the “guns vs. butter” debate. You may recall the phrase. It’s short hand for the ideological divide between those (mostly Republicans) whose priority is military strength and those (mostly Democrats) whose priority is investing in human capital (education, job creation) and social services (health care, etc.)

You are proposing a $54 billion (10%) increase in the defense budget. It’s highly doubtful Congress will go along with that and you have not as yet specified where that money is going to come from. There’s already political push-back. But the timing and size of this proposed increase are notable.

For one, there’s no obvious or demonstrated need. According to press reports, experts from both sides of the political divide say the US military is not in any kind of weakened state. And the Pentagon’s budget is already pretty YUGE, close to $570 billion, more than the next seven nations combined.

Secondly, there’s a broad emerging bipartisan consensus on the need for investments in job creation, infrastructure repairs, biomedical research, and, yes, even additional health coverage expansion. You have touted all of these.

In fact, my back of the envelope calculation indicates that $54 billion a year would expand coverage to an additional 12 to 15 million Americans through the exchanges over the next few years, including lots of young people if you tried hard to get them enrolled. You’d still have to find the money.

But, talk about your legacy! Now, that would be something. A Nixon-goes-to-China move for the ages: the president who came into office threatening to undo the most important health reform of the past 50 years ended up improving and adding to it and creating near universal coverage in the U.S. Wow. Ask around, see if your advisors don’t think that’s possibly a smart strategy.

If that’s the last bit intriguing, I suggest you convene a couple-day meeting of health policy wonks (conservative and liberal) to probe those Republican repeal and replace ideas you mentioned in your speech. Some are okay (HSAs, state flexibility, continuous coverage requirements); others (across state lines, high risk pools), not so much. Indeed, some have been tried before and failed. See this recent piece on high-risk pools, for example.

As you know, we are at a turning point in history when the perennial struggle between the forces of good and evil are becoming more present and obvious. In the context of health care, this struggle is between:

(1) health care as a right, with equalitarian access, a solid safety net, and progress and evidence-based innovation that enhances the health of the population, and national prosperity, and

(2) care as a consumer choice gamble, with an ever widening gulf in access to care between rich and poor, persistent gaps in the safety net, and an increasingly unhealthy population (think: opioid epidemic) that undermines prosperity and national security.

Which side of history do you want to be on?

Steven Findlay is an independent journalist, policy analyst, researcher and consumer advocate.

Categories: Uncategorized

4 replies »

  1. “The biggest threat to the health care “fix” is the intransigent grip of ideology.”

    Very true.

    Mirrors sometimes show more than one might like.

  2. Update 3/3 courtesy of Politico, which reports this pm that House Rs are not bowing to tea party group demands. The R&R bill WILL include refundable tax credits. But wealthier folks won’t be eligible, and staff have been told to come up proposals on that. The new draft — dated Feb 24 and to be voted on in 2 House committees next week — also still includes a phase out of Medicaid expansion. Capped payments to states would replace that for states keeping their expansions. All the Ocare taxes are still on the chopping block, as is the proposal to replace that revenue stream by capping the employer tax exemption. The new draft also proposes creation of a default reinsurance pool to stabilize the exchange markets for states that don’t opt into the “state innovation grant” program. See Polico’s piece at politico.com.

    Thanks Jim for your comments. Agree on $$ for cyber war prep, etc…but NSA has large budget on that, too. Needs to be better coordinated across the nat security and defense agencies. That’s long been a problem. On right v privilege. Semantics in a way. But I get your point that “right” is loaded word. “Moral obligation” is nice but lotta conservatives define that differently than liberals…it has more religious connotation for conservatives. And they don’t like to mix their religion with their politics and healthcare.

  3. Steve,

    Good piece. I’m sure he’s listening (but perhaps not). Your point about getting a CBO analysis first is right on. It gives him cover particularly IF he’s trying to find money for infrastructure and the military. I worry about our military. We don’t need it til we need it, and while the pertinent history is over 75 years ago, we are not in a position to be caught short defense wise. But my definition of of defense includes and would focus on the power grid and cyber-terrorism as much as anything. Defense more than offense. But no one asked me.

    I also try to avoid the “right vs. privilege” quicksand regarding access to healthcare. It’s something we do as a matter of principle (someone called it our moral obligation). But in any event, we ought to get over it and do it well. We understand that federal and state governments (i.e., our tax dollars) will pick up a huge portion. Let’s get over the who pays and move to the more important stuff of how much, why, etc.