David Coates

Wishing the Democratic Party a Healthy Easter Recess

Watching developments in American politics is rarely enjoyable these days. Indeed many of us periodically stop watching because the wear and tear on our nerve ends is so severe. So, it may be churlish to warn against taking too much pleasure from the Republican failure thus far to repeal and replace the Affordable Care Act. But the warning is still appropriate, I think, because unless the Democrats seize this opportunity to do more than simply gloat – and actually move the health care conversation on to new and bigger things – the euphoria we all felt on March 24th, when Paul Ryan pulled his plan back from a vote he knew he would lose, will not last long enough to help elect progressives to Congress in the key mid-term elections that are still more than a year and a half away.

I

Having said that, a little gloating is clearly in order, given the overwhelming barrage of vicious and hysterical right-wing criticism to which the Affordable Care Act was subject throughout the years of the Obama presidency. It was particularly sweet to hear Donald J. Trump, having once promised the abolition of “Obamacare” on Day 1 of his administration, concede in late February that health care reform was “unbelievably complex.”1 It was hugely enjoyable too to read, a month later, of town-hall meetings roasting Republican legislators as they returned to their constituencies from Washington DC,2 and to see video-clips of Joe Wilson’s constituents chanting at him “you lie”.3 If anyone deserved that chant, it was certainly him. It was also cheering to see that the Ryan plan which the Republican-controlled Congress failed to pass held on to so much of what is best in the Affordable Care Act; and there was much pleasure to be had in the fact that, in incorporating those elements to appease moderate Republicans, the Ryan concessions ultimately forced the conservative wing of the Republican coalition to reject it.

There was genuine pleasure too in having respected and politically-neutral bodies like the CBO confirm what Republicans had always denied: namely that the Affordable Care Act had managed to significantly increase the number of Americans with health insurance while lowering the trajectory of projected healthcare costs,4 while its much-touted Republican replacement placement would do neither of those things – or, if it achieved cost control, would only do so at the expense of throwing at least 14 million Americans off the health rolls again in its first year of operation, and as many as 24 million a decade later.5 Earlier CBO data, published while Barack Obama was President, also made it very clear that federal health programs are not in “the death spiral of exploding costs” that Republicans have long claimed – that in truth CBO estimates on spending on Medicaid and CHIP (the children’s health insurance programs) are lower now than they were in 2010, when the Affordable Care Act was first passed.6

But unfortunately, the Washington Post’s Matt O’Brien is right. For the libertarian wing of the Republican coalition, that really doesn’t matter. ‘They just don’t think the federal government should play any role in helping people get coverage, or telling insurers what that has to be.”7 Ultimately, it’s not about costs for them. It’s about ideology. No matter that their proposed replacement of Obamacare was immediately rejected by many insurance companies, hospitals, and even Republican governors. The important thing for them is that healthcare provision needs to be government-lite and market-heavy. The deepest irony of all, of course, is that if Republicans do eventually go off in that purely market-driven direction, many of the very people who voted for Donald J. Trump will be the ones most likely to be hurt, as a version of the AHCA replaces to ACA.8 But there can be no progressive pleasure in that: just anger at the dishonesty and foolishness of the man, and yet more frustration with the knowledge with how better life in America would now be if Donald J. Trump had lost the election in November.

So, whatever else will now happen in the national debate on health care reform, the recent debacle inside Republican ranks has certainly moved us all in the right general direction. Because of it, Republicans will no longer be able to hide behind empty rhetoric and derogatory labeling. They have their own plan to defend now – and that plan visibly under-performs relative to the Affordable Care Act that they so disparaged. The American Health Care Act is not superior to “Obamacare;” and progressives everywhere need to celebrate that, and to continually emphasize the degree to which “Ryan-care” or “Trump-care” – significantly, neither of them want the label – would take the United States back towards the very “hell” that they once claimed the Affordable Care Act was generating. All that is progress.

II

So why not just revel in the moment, and soak it for all it is worth? Two very big reasons spring to mind. One is that Donald J. Trump and the Republican Party have not given up on “repeal and replace.” The other is that, even if they do eventually give up on their attempt to repeal the Affordable Care Act, serious problems will remain with the Act that progressives need to both recognize and address. Because if we don’t recognize and act on those problems now, they (and no doubt the Republicans) will come back to haunt us yet.

The evidence that the fight is not yet over is plentiful, and scaring. Immediately after the Ryan plan was pulled, Donald J. Trump promised the Republican Party’s conservative wing that he would allow the healthcare system to fail and blame the Democrats for the failure.9 “The best thing politically,” he told The Washington Post, “is to let Obamacare explode.”10 Arch-dealmaker that he thinks he is, the President is currently trying to force the Democrats to negotiate a Ryan Plan Mark II by threatening not to give $7 billion to insurers in subsidies that allow low-income Americans to buy into the system. Democrats in Congress will no doubt resist that blackmail, but in truth there is much damage to the Affordable Care Act that his administration can do simply by making the threat in the first place, and by not defending the Act in federal court when (as now) the subsidies are being challenged. Inactivity alone can drive insurers from the exchanges, let the healthy young avoid penalties for ducking coverage,11 and deny would-be entrants to the health exchanges the guidance they need to make informed choices.12 Even if the Trump people don’t push the envelope that far, the Freedom Caucus has not gone away, Congressional Republicans are still trying to find common cause on healthcare reform,13 Tom Price (the long-time opponent of state-supported health coverage) remains as head of the DHHS, and outsider funding sources like the Koch brothers14 remain seriously committed to re-positioning the US healthcare system at the market-led end of the relevant policy spectrum, and away from the single-payer government-underwritten system favored by many progressive organizations and politicians.

Defending the Affordable Care Act in that climate will continue to be difficult, particularly given the problems that do now beset the system. Insurance premiums are likely to rise, the more that the pool of healthy-insurers is reduced by any tinkering with the individual mandate. The number of insurance companies willing to stay in the exchanges of the Affordable Care Act is dwindling, so that the idea that competition between insurers will bring health costs down already has an increasingly hollow ring.15 And even if the rate of increase in insurance premiums does remain low (which is highly unlikely), much of the benefit of that will not necessarily be felt by working Americans, accompanied as health insurance is these days with every greater co-pays and policy exclusions.16 Big Pharma remains out of control because of inactivity by US legislators, able to charge more for drugs here than even in neighboring Canada, and the backlog of accumulated illnesses among those still excluded from access to health insurance means that any further extension of coverage will inevitably put pressure on profits across the system as a whole, and additions to insurance premiums for those already long insured. One over-riding truth of the Affordable Care Act right now is that “for too many people, health plans in the individual insurance market are too expensive and inaccessible.”17 Another is that more than 28 million Americans remain uninsured, and many more remain under-insured. Given the scale of the problems it sought to address, the ACA was a definite step forward, but robbed of its public option by horse-trading in Congress and of full Medicaid expansion by Supreme Court ruling, it was never forward enough – and it remains vulnerable to criticism, even when that criticism lacks a partisan edge.

The only way to save the Affordable Care Act, given the limitations of the Act and the hostile political atmosphere now surrounding it, is to use it as a launch pad for yet more fundamental healthcare reform; and now is the time to make the argument for that reform again, when the more market-based Republican Party alternative is so widely discredited. So, what should the core elements of that argument be?

III

These five, at least.

A recognition that there are only so many ways to run a healthcare system, each with strengths and weaknesses that an open debate should carefully map. We need to get away from any notion that there is one perfect way of providing health care. There isn’t. There is simply a spectrum from “market-based” provision through “insurance-based” provision to “state-based” provision. Market-based provision encourages personal responsibility, and sets no limits on what healthcare you can buy if you have the money to do so. But of course, if you don’t have the money in the first place, access to healthcare falls rapidly away. At the state-based end of the system, there is no problem of access – everyone is entitled – but cost control is tough, and personal responsibility low on the agenda. Insurance based systems balance the two, but leave insurance companies in the driving seat, with under-insurance as well as no insurance as a perennial problem. Insurance-based systems also generate uncertainty about the reliability of coverage, if insurance is tied to employment. What if you lose your job? So, the weaknesses vary, depending on which system is in play: but all of them involve rationing. There is never enough healthcare to go around. Market-based systems ration by price, insurance-based system by coverage, and state-based system by time. In the latter, you wait: and if those state-based systems work well, it is doctors who determine the urgency (and therefore priority) of treatment, not the size and detail of your insurance package.

A recognition that the US healthcare system remains a mosaic of those systems – and in that mishmash of types of provision lie so many uniquely American problems that a tidying up can only help to alleviate. Most leading economies have one national system – state-provided in the UK and state-dominated in Canada, insurance-based in Germany and in France. We don’t. We mix all three – insurance-based for most working adults, state-based for the poor and the old, and market-based for those without employer-provided health insurance. We get all the weaknesses of each system, and few of the strengths: higher administrative costs, defensive medicine to the degree that insurance companies allow, boundary problems as we move from one category of patient to the next, and big wait times for Americans without coverage at all (just a last-minute dash to the emergency room). Add to that the excessive salaries of health insurance CEOs and the excessive salaries paid to health specialists, and you begin to see why the US spends so much greater a proportion of its GDP on healthcare than do other leading industrial economies. We even pay our primary care providers on a fee-for-service basis, rather than a per capita one – a payment system guaranteed to encourage over-prescribing and to discourage the proliferation of preventive medical advice.

A reassertion of the core progressive position: namely that healthcare should not be treated as a commodity – something to be bought and sold – but as a basic right, unconnected to either employment or income. The cat is really out of the bag on this one now, after Paul Ryan left everyone ‘free to choose’ healthcare while omitting to discuss whether the choices faced by the poor were as big as those faced by the rich. Healthcare isn’t something to buy, like broccoli or beans. Consumers don’t have the knowledge. Local healthcare suppliers have the monopoly, and anyway, if you need heart surgery, you can’t test- drive four local hospitals to see which heart you like best. Ryan may think freedom lies in formal rights to choose rather than in real capacity to buy: but if so, he is entirely wrong and deeply immoral.18 There is such a close relationship between illness and poverty that the very people who need access to healthcare most are the ones least able to obtain it in market-based systems. It is therefore so much better to treat healthcare as something we all need at some points in our life, to note that those needs vary by gender as well as by age, and to stop financing access through employer-subsidies rather than through general taxation: because employer subsidies add to business costs, slow rates of labour mobility, and build vast inequalities into the healthcare system. We wouldn’t tie voting rights to employment, so why should we tie access to healthcare.

A recognition that prevention is better than cure, that a healthy society creates healthy people, and that when it does (and only when it does) personal responsibility for life-style choices becomes a legitimate element in the design and funding of any healthcare system. Libertarians like to think that people exist alone, and are free the more they stand alone. They are wrong. Your health is important to me. It helps make my world healthier, just as my health should be important to you. There are three unavoidable contracts here. One is between the healthy and the sick – the individual mandate – each of us contributing when we are well so that we can benefit when we are not. The second is between the economy and its people. The more the economy is organized to keep people well – by paying them properly, allowing them flexible work hours and down-time with family – the less illness we will see, and the less healthcare we will need to pay for. And in that sort of economy and society, there is a third contract too: a contract between the individual and his/her peers, not to add to the costs they pay for healthcare by failing to be healthy ourselves, by failing to eat healthily, by failing to take exercise, and so on. Any redesigned healthcare system needs a full public conversation about all three of those contracts, about the relationship between them, and about the relative importance of each.

The need to avoid reinventing the wheel – by drawing on the best of the rest abroad for the design principles to deploy. Other countries battle with these issues too, and we would do well to learn from the best of the rest abroad. The German healthcare system has lots to teach us about how to regulate private insurance companies to avoid “adverse selection” – their desire only to insure the healthy. The Canadian system has much to teach us about how to reduce the market-power of Big Pharma; and the French have a sophisticated set of rules governing co-pays, rules that encourage people to go to their doctors for preventive care, but not to go so often just for yet another pill. Any serious comparison of different healthcare systems must generate a public conversation about “floors” and “ceilings” – about what should the minimum level of healthcare for everyone be, and how high can the ceiling go if people are allowed to spend their own money on more healthcare services. And any serious comparison should also help us on revenue flows. Is it best to finance healthcare out of general taxation, payroll taxes, sales taxes, or high co-pays? The British have lots of teach us on that!19

IV

My own personal view is that, when those five conversations have been worked through carefully, the case for moving towards a single-payer system becomes ever stronger.20 But the crucial thing now is not my opinion, or possibly even yours. The crucial thing now is for progressives within the Democratic Party and beyond to insist on us having this conversation again. For seven long years, the Republicans blocked an intelligent public dialogue about healthcare by telling us that the Affordable Care Act was a disaster, and that a more market-based system could be easily introduced that would be better. Well, they blew that big time in March. Now it is our turn, to lift the quality and volume of the conversation again. If voters are to make intelligent and informed decisions, they need to be provided with intelligent and informed political leadership. Come on Democrats. Now is your chance. Please seize it: on and up to a fully comprehensive, publicly managed healthcare system in the United States at long-last. Then we can all stop worrying about healthcare, and just get on with the serious business of becoming healthy!

David Coates’ commentary on the second Obama term is now available as The Progressive Case Stalled.21

Commentary on both terms is now gathered as

Observing Obama in Real Time.22

For something entirely different, and much more fun, see Lying Close to the Sky.23

1 Robert Pear and Kate Kelly, “Trump Concedes Health Law Overhaul is ‘Unbelievably Complex’,” The New York Times, February 27, 2017: available at https://www.nytimes.com/2017/02/27/us/politics/trump-concedes-health-law-overhaul-is-unbelievably-complex.html?_r=0

2 Alice Ollstein, GOP Lawmakers Have Lot Of Explaining To Do Back Home About O’care Debacle, posted on TPM, April 10, 2017: available at https://talkingpointsmemo.com/dc/republicans-aca-obamacare-health-care-recess

3 Lindsey Bever, “You lie!: Constituents just used Rep. Joe Wilson’s own line against him,” The Washington Post, April 12, 2017: available at https://www.washingtonpost.com/news/powerpost/wp/2017/04/12/you-lie-constituents-just-used-rep-joe-wilsons-own-line-against-him/?utm_term=.ce706b393459

4 Harry Stein, The Obama Health Care Legacy: More Overage and Less Spending. Washington DC: Center for American Progress, March 25, 2016 https://www.americanprogress.org/issues/economy/news/2016/03/25/134074/the-obama-health-care-legacy-more-coverage-and-less-spending/

5 Amy Goldstein, Elise Viebeck, Kelsey Snell and Mike DeBonis, “Affordable Care Act revision would reduce insured numbers by 24 million, CBO projects,” The Washington Post, March 13, 2017: available at https://www.washingtonpost.com/powerpost/obamacare-revision-would-reduce-insured-numbers-by-24-million/2017/03/13/ea4c860a-0829-11e7-93dc-00f9bdd74ed1_story.html?utm_term=.12bbbaccd887

6 Henry Stein and Alex Rowell, New Data Delivers Good News for Health Care and Bad News for Speaker Ryan’s Tax Reform Plan, Washington DC: Center for American Progress, March 30, 217: available at https://www.americanprogress.org/

7 Matt O’Brien, “Republicans can’t find a way to repeal Obamacare because too many of them secretly love it,” The Washington Post, April 14, 2017: available at https://www.washingtonpost.com/news/wonk/wp/2017/04/14/republicans-cant-find-a-way-to-repeal-obamacare-because-too-many-of-them-secretly-love-it/?utm_term=.43acfd0a477e

8 Philip Bump, “Once again: The Republican healthcare plan affects Trump-supporting places more negatively,” The Washington Post, March 14, 2017: available at https://www.washingtonpost.com/news/politics/wp/2017/03/14/once-again-the-republican-health-plan-affects-trump-supporting-places-more-negatively/?utm_term=.0eb32fc703cf

9 First Amendment, Trump Promises Tea Party Groups He Will Punish America: If Trumpcare Fails, He Will Let ACA Fail. Posted on Daily Kos, March 10, 2017: available at http://www.dailykos.com/story/2017/3/9/1641791/-Trump-Promises-Tea-Party-Groups-He-Will-Punish-America-If-TrumpCare-Fails-He-Will-Let-ACA-Fail

10 Steven Rattner, “Pushing Obamacare Over the Cliff,” The New York Times, March 28, 2017: available at https://www.nytimes.com/2017/03/28/opinion/pushing-obamacare-over-the-cliff.html

11 Ashley Parker and Amy Goldstein, “Trump signs executive order that could effectively gut Affordable Care Act’s individual mandate,” The Washington Post, January 20, 2017: available at https://www.washingtonpost.com/politics/trump-signs-executive-order-that-could-lift-affordable-care-acts-individual-mandate/2017/01/20/8c99e35e-df70-11e6-b2cf-b67fe3285cbc_story.html?utm_term=.d0e14273c534

12 Dana Milbank, “Trump is now destroying a healthy health-care system,” The Washington Post, April 14, 2017: available at https://www.washingtonpost.com/opinions/trump-is-now-destroying-a-healthy-health-care-system/2017/04/14/20873740-211d-11e7-be2a-3a1fb24d4671_story.html?utm_term=.ed0286b98d29

13 Robert Pear and Jeremy W. Peters, “Repeal of the Affordable Care Act Is Back on Agenda, Republicans Say,” The New York Times, March 28, 2017: available at https://www.nytimes.com/2017/03/28/us/politics/health-care-obamacare-freedom-caucus.html

14 Richard Eskow, Koch caucus continues its assault on healthcare. Posted on NationofChange newsletter, April 10 2017: available at http://www.prwatch.org/news/2017/04/13233/koch-caucus-continues-assault-healthcare

15 Carolyn Y. Johnson, “Another state is at risk of having only one Obamacare health insurer,” The Washington Post, April 6, 2017: available at https://www.washingtonpost.com/news/wonk/wp/2017/04/06/another-state-is-at-risk-of-having-only-one-obamacare-health-insurer/?utm_term=.ac468e594a3b

16 Topher Spiro, Maura Calsyn and Meghan O’Toole, The Great Cost Shift, Washington DC: Center for American Progress, March 3, 2015: available at https://www.americanprogress.org/issues/healthcare/reports/2015/03/03/105777/the-great-cost-shift/

17 Robert Pear, “Ailing Obama Health Act May Have to Change to Survive,” The New York Times, October 2, 2016: available at https://www.nytimes.com/2016/10/03/us/politics/obama-health-care-act.html

18 Theresa Brown, “The Moral Failings of Obamacare Repeal,” The New York Times, March 11, 2017: available at https://www.nytimes.com/2017/03/11/opinion/sunday/the-moral-failing-of-obamacare-repeal.html

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David Coates holds the Worrell Chair in Anglo-American Studies at Wake Forest University. He is the author of Answering Back: Liberal Responses to Conservative Arguments, New York: Continuum Books, 2010.

He writes here in a personal capacity.

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