Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
How to Fix the GOP’s Health Care Fix
In my new The Week column, I express concern that failure to reform Obamacare today may push America toward a single-payer health care system tomorrow. Given that the ACA was passed in 2010, I’m not sure how many bites at the apple remain for Republicans. FreeMarketCare when? Will we at least be headed that way directionally sometime soon?
Now if you want to read two pieces on the new House GOP health care plan, definitely read my The Week piece. But as fantastic as it is, if you are only in the mood to read one thing on the topic, let me enthusiastically recommend a new column by my AEI colleague Jim Capretta. It’s chock full of real-talk goodness. Such as this:
In combination, the policies in the House bill would lead to a very large increase in the number of Americans without health insurance. It is true that all Americans could get insurance if they wanted to, but many households will see their options get worse under this plan compared to the ACA, not better. The Congressional Budget Office (CBO) is sure to make these points when its estimate of the plan is released in the coming days.
But it’s not all negative. Capretta has several ideas to fix this Obamacare fix:
Published in HealthcareFirst, the GOP must compromise on Medicaid. Thirty-one states expanded Medicaid under the ACA, while nineteen did not. It is possible to find a compromise that allows all states to provide safety-net insurance up to a uniform national level of income. The program could then be reformed to allow more state flexibility within a framework of fixed federal spending per enrollee. The federal government financial commitment to the program would not be cut dramatically in the near term. But, if done right, a compromise of this kind would represent a fundamental reform of the program that would lower long-term costs and improve the health outcomes for the program’s participants.
Next, the GOP should address the value of the tax credits for households just above Medicaid eligibility. It is not necessary to replicate the ACA’s credits, but it is also important to recognize that households at 200 percent of the federal poverty line (around $24,000 for a single person) will need more than $2,000 or $3,000 or even $4,000 to get a health insurance plan.
Finally, the GOP needs to aggressively pursue automatic enrollment into health insurance for persons eligible for the refundable tax credits but who fail to select insurance plans on their own. … This kind of automatic enrollment system, done correctly, could boost dramatically the number of people with insurance under both the ACA and replacement legislation.
That is fine if 33 states want the expansion to stay that does not mean taxpayers in all 50 states have to pay for it. Let each state who wants to force their taxpayers to pay for It, pay for it not me.
So much criticism, so little guidance. I took a few swings at this issue here. We can get the market involved, but it requires larger thinking. What is holding the market back? We purchase our healthcare from insurance companies. How stupid is that? We have no idea what our care will cost when we take that terrible step to seek it. How dumb is that? We are asked to pledge every single cent we have or will have before we receive care, regardless of how much or how effective. How insane is that? People who pay cash pay more, substantially more, for care. Name another instance in a market economy where that is the case. We call prepaid health care insurance. We let our employers purchase our health care for us, they use our own money to do it and then compromise our compensation when the premiums go up. Policies are a tangle of incomprehensible deductibles, copays, out of pocket maximums and other features that we do not understand. Hospitals have pricing policies that are both anti-competitive and ridiculous. This is what happens when accountants purchase health care for the ignorant and gullible. Government allows drug companies to fix prices and gouge people. With respect to Medicare and Medicaid, the government gouges the caregivers and drug companies. Doctors order care based upon reimbursement rate, not need. Doctors order care because they don’t want to be sued. Lawyers sue doctors and hospitals on a whim, and the plaintiffs settle. I could go on and on. If we address those absurdities, health insurance and health care start to make sense.
@dougkimball on a scale of 1-10 that’s at least a ten.
Hi James,
Liked your post in the Week much better:
A nice snippet:
“A smart, comprehensive, center-right plan would have tried to significantly expand the role of markets and consumer choice in the American health-care system. Many conservatives, for instance, wanted a plan that would give Americans more control over their health-care spending and allow them to take their plan from job to job.”
If only Mister Ryan and friends et al had taken that approach, but one could only guess what they were thinking behind those very closed doors when they came up with this piece of stinking you know what. Kinda looks like the highly paid lobbyists got first dibs on what was going to be in the bill, doesn’t it? Ah to be so bought and sold! What a contorted mess!
This bill could easily be the undoing of the Trump Administration right out of the gate.
I agree!
James P and I don’t see eye to eye on much…but we agree on this. 100%
It’s clear as mud.
Can anybody explain the procedural hurdles regarding passage in the US Senate which I understand will the the eye of the needle this particular camel will have to pass through. Some legislation will require 51 votes, some will require 60 votes? Some legislation is tied to existing law and how it was passed into law in congress under Obama.
I hear one Liberty Caucus congressman say this plan is aimed at the 20 million uninsured or hard to insure rather than the 300 million American people. He would like to see a plan that primarily addresses the latter.
Where is tort reform?
Where is price competition across state lines?
Does this plan incorporate some pain for EVERY health customer (including congressional and US government health plans), so that market forces can work.
Can health savings plans start at birth so that compounding can occur to help pay for future expenses?
What penalties are incorporated in this health care scheme for behavior that leads to high medical expenses like smoking or certain kinds of sexual behavior?
This Republican initiative is already being labeled Trumpcare or/or GOPCare.
This is a very good explanation. The whole thing revolves around US Senate rules,
https://www.youtube.com/watch?v=iHfcNhmKYfo
One of the most important parts of current health care reform.
https://en.wikipedia.org/wiki/Byrd_Rule
The GOP has 51+ votes in the senate. It doesn’t have any way to reach sixty on health care.
The stuff that is not there is the non-budget elements in the basic Bill that can’t be passed without surviving a filibuster. The problem is that even though Capretta is right, even this lower level reform that does a lot to fix Medicaid and moves toward individual control via the tax credits, the usual green eyeshade types- who don’t want to fix the problem, they just want to kill everything and give the Dems a free ride to single payer- will destroy the baby before it can take any baby steps.
The Right has no hope of moving toward free markets because Sen. Paul (who is responsible for ObamaCare stiull existing today because he made sure it didn’t appoly to Congress), FreedomWorks, Heritage Action, the Club for Growth and Americans for Prosperity all insist on perfection today which is impossible without some Dem support.
Doug, your points are well taken, but you err in one basic case- you assume that the docs are innocent victims here being gouged by the government. They are at least as bad as the government, and worse than most insurance companies, using fed and state regulators to prop up unsustainable monopolies.
https://abetterway.speaker.gov/
https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-Snapshot.pdf
Q: But why isn’t this one big bill that Congress will vote on?
A:This approach presents a bold alternative to the status quo and a foundation for multiple pieces of straightforward legislation, not a comprehensive, overly complex, and confusing 3,000 page bill. Successfully translating these ideas into action requires a step-by-step approach.
Q: Does this plan repeal Obamacare and when?
A:Yes. People have been hurt by Obamacare’s disruption, so our plan also allows for a realistic, modest transition period to get our new system up and running. We can’t take away people’s coverage while they wait so there is a transition period to give patients and markets stability, but it will be implemented as quickly as possible.
https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-BytheNumbers.pdf
So let me see if I understand….
First we were told we couldn’t stop Obamacare because we didn’t control either the House or the Senate or the Executive. So we worked hard and gave them the House.
Then we were told that we were barely one half of one third of the Federal government. If they had control of the Senate, then by God, we’d see something! So we gave them the Senate.
Then we were told that the President would only veto. So the thing was moot.
So now we gave them the Presidency. And now they’re bellyaching that they don’t have 60 votes ?!?!?
Sounds very much like a group determined to do nothing unless driven to it and then, if they have to, to do the absolute minimum.
When you don’t have sixty votes you don’t have sixty votes. In some ways the US Senate rules are very “conservative.” From what I can tell the Ryan plan has some chance of working. It will require a herculean effort by the GOP leadership, the cooperation of the conservative wings of the house and senate, and a major push by Trump. Later it will take a truck load of carrots and sticks to obtain nine Democrat senate votes (ten Democrat senators are up for reelection in states Trump carried). We shall see. We will get to see how good the Trumpster is at lobbying congress. We might be surprised.
Doctors, like any red blooded American seeking the dream, are smart and will use the system, even abuse it. My wife’s best friend is a pediatrician at a county hospital. Just last week she told me this, with a straight face. I paraphrase: “I told the administrators I can do marketing. We get $60 dollars for a fluoride treatment (Medicaid). We should swab the teeth of every Medicaid kid we get in here, no matter why they’re here. They never see a dentist so they all have bad teeth. We’re helping them and we get another $60 a pop.” When I mentioned that this was at least unethical, she again mentioned how bad these kids’ teeth were. “They’ve never seen a dentist.” She was convinced that this was a brilliant stroke. And, by the way, she’s a Trump supporter.
For the record, at the end the Dems didn’t have sixty votes in the Senate either and yet Reid and Pelosi managed to get Obamacare passed. It looked like they never broke a sweat let alone undertook a Herculean effort (which is a good thing because old Harry almost killed himself with an exercize band … Forget Herculean). Do they know more Congressional ninjitsu than Ryan and McConnell?
Apparently.
To quote impeached Democrat Rep. Alcee Hastings of the House Rules Committee during the bill process: “We’re making up the rules as we go along.”
http://www.briansussman.com/politics/how-obamacare-became-law/
To summarize Capretta’s article: “the GOP bill should look much more like Obamacare”.
I think all of us need to face a painful fact: if we’re going to stick with the basic structural framework of the PPACA (namely trying to cover all Americans through a hybrid of direct government spending and a private system based on community rating), then the PPACA is already the best law for that purpose. And why shouldn’t it be? It had a lot more people who were a lot more devoted to its cause spending a lot more time developing it. They thought through every contingency and came up with the most efficient solution for their chosen structure.
In other words, if we’re not willing to change the central pillars of the Obamacare architecture, there’s really no point in trying to change it at all – anything we come up with is likely going to function less efficiently than what’s already been enacted.
This is truly a case of go big, or go home.
“Blooie!”
That’s kind of what I’ve been thinking, at least in relation to the main GOP bill. What about the Cassidy-Collins bill though? It’s more of a “if you like your Obamacare, you can keep it” type of bill, and gives the states leeway to decide what to do, if I’m not mistaken.
Wait…it didn’t get passed until March 2010 though, and they had to drop the public option, satisfy pro-life Democrats, etc. It took awhile and was pretty complicated. Plus, they did have 59 seats, while the Republicans have 52. And they had to use a legislative trick – the ACA was not passed via reconciliation. They did have 60 votes and it was passed 60-39, with cloture. They passed another bill a week later via reconciliation to amend it. Wikipedia discusses it here. The amendment included provisions that four senators couldn’t vote for, and the overall ACA couldn’t be passed via reconciliation because it included non-budget elements. So they had to pass the ACA first with 60 votes using cloture, and then the amendment bill using reconciliation.
Paul Ryan’s American Health Care Act (Obamacare Replacement) PowerPoint Presentation
“If Ryan wants to limit his argument to insisting that this is the best Republicans can come up with given the fragile Senate majority and the complicated parliamentary maneuvering required to secure passage, it would still be a faulty argument, but at least it would be within the realm of debatable. But calling this federal healthcare scheme “conservative” just because Republicans were the ones to concoct it is a farce.”
http://www.washingtonexaminer.com/speaker-ryan-this-is-not-what-conservative-reform-looks-like/article/2616998