The failure of the House to bring Ryancare/AHCA to vote last week has succeeded at inspiring a barrage of insightful essays about this very complex issue. My synthesis of these insights is forthcoming. Here are some of the new pieces of the healthcare puzzle for now.
The existing ACA has two big components: the expansion of Medicaid and the private insurance exchanges. Only the latter is broadly exposed to “hastening an implosion” by Secretary Tom Price or Trump’s Executive orders. The Federal government currently props up the Health Insurance providers when a state market is not lucrative enough to offer insurance. Those subsidies could be discontinued, forcing insurers to raise premiums, increase deductibles or pullout of the exchange entirely.
The health insurance offered to “hard working Americans” is mostly a bunch of junk policies. The premiums and deductibles are repellant. The policies include the cancellation if the policyholder starts filling big claims for illnesses that were not preexisting. The voters’ pushback against the “health insurance mandate” in the ACA could be more about those junk policies than against contributing to the common good by being insured like everyone else. They want freedom of choice, not freedom from health insurance.
Health insurance companies have been more profitable than ever since the ACA was enacted. They are getting out of the business of aggregating the health costs risk and simply providing administrative services for big employers who have become self-insured. The biggest consumer of conventional health insurance policies are those citizens on Medicaid who use Federal money to buy policies.
A majority of voters now want single payer, Medicare for all, insurance. They are benefiting from the ACA and do not want it taken away. They want it improved, simplified or expanded. The government can no longer be trusted to formulate and pass a complex piece of legislation. The 17% approval rating of AHCA provided how clueless Congress is about considering diverse constituencies. They appear far better suited to make enemies of the State Governors, seniors, disadvantaged citizens, physicians, private healthcare providers and more. The Republicans are expected to take a hit in the midterm elections next year, whether they were in favor of or opposed to the AHCA.
Lots of the voters for Trump could have just as easily voted for Bernie Sanders. These voters are not located on the political spectrum where political issues spawn loyalties. These voters want change from the do-nothing government that answers to special interests and hostile campaign funding sources. They want a return to “consent by the governed” as if we are living in a democracy, not an aristocracy or oligarchy.
The adversarial tactics of the Freedom Caucus appear to be more focused on Republican lawmakers than on the AHCA itself. They suspected the late night “closed door sessions” to formulate the AHCA was only Paul Ryan meeting with health insurance company lobbyists. The loyalists to Speaker Ryan need to be exposed, humiliated and discredited. The Freedom Caucus’s blocking the passage of the “undemocratic” bill worked superbly toward their objective.
Trump’s approach to negotiating the passage of the AHCA indicates that he doesn’t really care what is in the healthcare legislation. All he wants is a win. He leaves it up to the legislators to resolve their differences, just like he left the architectural and engineering plans up to those professionals in his real estate deals. He expected that the Republicans had been preparing blueprints over the seven years they were raised a stink about “repeal and replace Obamacare”. He discovered he was working with a bunch of loudmouth amateurs in Congress. #sad! He has not discovered who else is a loudmouth amateur in power just yet.
Trump’s only “skin in the game” is for a personal win. This could be making him increasingly amenable to working with Democrats on upgrading the AHA. He also has clearly demonstrated that he is pragmatic, not ideological. He’s inclined to do what works to gain popularity with some interest group, though not the same one all the time. Pragmatism does not make for consistency, but it does make him susceptible to bait that promises approval and adulation. Democrats have been dealt a hand to be played strategically, not politically.
All this is shaping up into a wonderful opportunity for universal health coverage in the near future. I will explore how that could unfold in my next post.