Repealed and Misplaced

Like Joe, Michael and others, I find myself wondering what, if anything, Trump learned from the demise of the AHCA last Friday. But I’m also wondering what Democrats and other Republicans are thinking. The question I would like to ask all Republicans is: Is it clear to you now that merely saying no to any Democratic proposal to lower the uninsured rate is bad for your party? The question I would like to ask all Democrats who supported the Affordable Care Act is: Is it clear to you now that that the managed care nostrums in the ACA cannot lower costs, and that attempting to lower the uninsured rate without cutting costs is bad for your party?

Here’s my short answer to these questions: Trump didn’t learn anything about health policy but he did learn not to trust the Freedom Caucus; Republicans did learn that saying “hell no” is bad for their party; and I haven’t the faintest idea whether elected Democrats (as opposed to the Democrats’ base) are finally ready to look outside the Book of Managed Care for solutions to high US health care costs.

Let me start with Trump. I doubt he learned a darn thing other than “health care is complicated” and the Freedom Caucus cares more about their anti-government religion than they do about Trump or the GOP.

I might have entertained the possibility that Trump is capable of learning if he had made statements Friday night aimed at reassuring nervous insurance companies that he and Tom Price will work overtime to stabilize the individual markets. But Trump didn’t do that. Instead he used his TV time to state over and over that Obamacare will “explode.” A man with any brains would have realized that Obamacare is still the law of the land and is now his responsibility, and if he deliberately sabotages the exchanges the public will assign much, perhaps all, of the blame to him and the GOP.

Trump’s inflammatory statements come at a time when the exchanges are extremely vulnerable. Trump had already weakened the exchanges by instructing the IRS not to reject tax returns that fail to tell the IRS whether the filer has insurance, and by leaving the insurance industry in the dark about how he intends to resolve House v. Price(formerly House v. Burwell, the case in which a federal district court held that Congress never authorized funding for the subsidies for out-of-pocket costs for people under 250 percent of the poverty level). His gratuitous fear-mongering Friday night will only further weaken the exchanges.

The next most important question for Republicans is whether the non-suicidal wing of the Republican party learned anything. Surely all sane Republicans now know that obstructionism is no longer a surefire way to build the Republican party. Unadulterated obstructionism has been the GOP’s position on health policy affecting the non-elderly since 1993 when William Kristol and then Representative Newt Gingrich began their campaign to persuade congressional Republicans to refuse even to negotiate with Democrats on the Clintons’ Health Security Act (HSA).

In December 1993, William Kristol, then with the Project for the Republican Future, privately circulated a memo http://talkingpointsmemo.com/edblog/the-1993-kristol-memo-on-defeating-health-care-reform telling Republicans that “simple criticism is insufficient” and that Republicans must demand “surrender” and should “erase” and “kill” the HSA. Kristol did not present an alternative to the HSA. His argument was purely ideological (the Clintons were going to “destroy” the health care system) and Machiavellian (“[The HSA] will …. strike a punishing blow against Republican claims to defend the middle class by restraining government.”) Gingrich promoted the same message — just say no, and don’t offer an alternative. His Contract with America had nothing to say about health care other than, “We don’t need a government-run health care system.”

By 1994 Republicans were not only willing to be public about their Hell No strategy, they bragged about it. It paid off. The HSA went down in flames in September 1994, and Republicans took control of both houses of Congress two months later. The November 1994 election was one of the worst mid-term setbacks to a sitting president in US history.

The advantage of the Hell No strategy was that Republicans never had to declare whether they supported universal health insurance, or even cared enough about the uninsured to go beyond occasional handwringing about the problem. But Republicans gradually gave up that advantage after the enactment of the ACA in 2010. They weakened that advantage first by adopting the “repeal and replace” mantra; now they were at least officially in favor of “replace,” something they had never promoted before. The unveiling of the AHCA, the release of the CBO report on the AHCA, the near universal opposition to the bill by provider organizations, and the demise of the AHCA last Friday obliterated what was left of the Hell No advantage. Now the entire world could see that Republicans cared so little about reducing the uninsured rate, never mind achieving universal coverage, that they never bothered to develop an alterative to Obamacare, much less one that was better than Obamacare.

The ACA, for all its defects, did one thing good for this country: It forced Republicans to come out of their Hell No bunker and put up or shut up. And when Ryan and Trump put up, the vast majority of Americans and a significant number of congressional Republicans wrinkled their noses and said that wasn’t good enough.

I agree with those who suggest Trump might eventually ask Democrats to help him figure out how to improve the ACA. If he does, Democrats will feel compelled to at least appear to be negotiating. But even if negotiations come to pass, what could Democrats propose to Trump that Trump might be interested in beyond tiny tweaks to the ACA? All Hillary could propose was more bailouts for the insurance industry and more money for “navigators.” I think the best we can look forward to is bipartisan tweaks — letting insurance companies charge older people more, for example.

I wish I could say with some confidence Democrats will soon start thinking seriously about abandoning their ancient obsession with overuse and the managed care “solutions” the overuse diagnosis naturally leads to, and start focusing instead on high prices and the administrative waste and galloping consolidation(encouraged by managed care solutions) that drive prices up. (Note to Jim Purcell: Jim, please read my comment on the overuse obsession here https://thehealthcareblog.com/blog/2016/10/06/underuse-is-rampant-but-overuse-is-all-we-talk-about/. You are welcome to use anything you see there in your book.) I also wish I could say the awful price Democrats have paid for the defects in the ACA and the demise of the AHCA has emboldened Democrats to start thinking seriously about how we extend the traditional Medicare program (not the Medicare Advantage program) to the non-elderly (in stages if necessary).

But at the moment I can’t say the Democratic leadership is ready to abandon the overuse diagnosis and all the managed care fads that were endorsed by the ACA. A large portion of the Democratic base wants a debate about Bernie’s and and Rep. John Conyers’ Medicare-for-all legislation. But what does the leadership of the party think? Who knows?

Over the last four years, elected Democrats at all levels, and ACA supporters generally, have responded to the constant bad news about Obamacare like deer staring at headlights on a Mac truck. They knew they were about to become roadkill, but they didn’t know what to do about it, so they froze in the crouch position as the lights bore down on them. And now that they have survived being run over, what are they thinking? They know the Affordable Care Act was a significant factor in their losses in 2010, 2014 and 2016, but are they now ready to concede that their high hopes for the managed care cost-containment nostrums in the ACA were based on faith, not evidence, and that that faith severely damaged their party? Who knows? To continue the deer-in-the-lights analogy, they appear to be coming out of their crouch and thanking the gods they didn’t get killed, but they’re still in the middle of the road and too confused to know what to do next.

The Democrats have suffered the political equivalent of a near-death experience. Near-death experiences can cause people to develop fresh thinking about old problems. But they can also cause PTSD and make people fearful of change. I predict that that over the next two to four years the PTSD effect will rule Democratic strategy even as a large portion of the Democrats’ base demands fresh thinking. I predict, therefore, that even if Trump decides to approach Democrats for help fixing the ACA during this session of Congress, Democrats won’t coalesce around Medicare-for-all but will instead cooperate with some tinkering with the ACA and some tinkering with a few other health-related programs, possibly including MACRA.

Here’s one wild card I suggest we all watch out for: Revival of Paul Ryan’s proposal to complete the privatization of Medicare with a voucher program. Trump has shown repeatedly he is willing to lie and break promises. He just broke possibly the biggest promise of his campaign — the one about repealing and replacing the ACA. (If he didn’t break it, why didn’t he promise to return to this issue soon?) Might he not also break his promise to leave Medicare alone? I can see him doing it to free up some money for his tax cuts for the rich, his infrastructure proposal, and his military build-up.

If Trump and Ryan decide to push Ryan’s voucher program, Democrats will face a problem. They told the public that a voucher program was good for the non-elderly (the Obamacare premium subsidies are the equivalent of vouchers), so how do they now take the position that vouchers for the elderly are bad? Will they resolve this contradiction in favor of abandoning support for the ACA and supporting Medicare-for-all? One can hope.

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