Real fixes for Obamacare

“I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead— the Republicans will do much better!”— President Trump, in a post Sunday evening on Twitter, capitalizing the “H” in health care for some reason, and capitalizing the “C” in care within Obamacare for no reason, and otherwise making, per usual, no discernible sense at all.

Having suggested that Democrats act righteously and responsibly and propose them, I got asked the difficult question of what fixes for Obamacare would look like.

The question implied seriousness instead of the charade Republicans passed laughably in the U. S. House of Representatives a couple of weeks ago. The preposterous second- place president, Donald Trump, held a victory celebration on that debacle, spiking the football after making no gain on the play.

The elements and objectives of real fixes are two. The first is to get everyone participating in the health- insurance pool so that premiums could be kept reasonable. The second, for fairness and decency and humaneness, is to charge those with expensive conditions the same rate for health insurance charged everyone else.

And it’s to provide that the often-steep additional costs of that extended acute care would be paid by a separate pool neither oppressing the diseased nor affecting general premiums for everyone.

There are only three practical means of achieving more nearly universal coverage. The first is to make the tax penalties for being uninsured more severe, so punitive as to be a deterrence to going without insurance. The second is to get more healthy and robust young people to enroll, a goal that could better be achieved by those stiffer tax penalties, but aided by some form of special bare- bones health insurance for, say, persons under the age of 35. The third is not to dare, as House Republicans dare, to end the vital Medicaid expansion for the poorest working people.

People over 65 have their own health- insurance offerings. So could it be for those under 35. Bare- bones econo- plans would raise at least some dollars for the pool from robust younger people typically not facing the same health- maintenance costs of the older among us.

Many pay nothing now. Something is better than nothing.

Obamacare provided for getting all the poorest people covered by expanding Medicaid and requiring states to accept the expansion or face sanctions in federal turnback for basic Medicaid. The U. S. Supreme Court, in otherwise upholding Obamacare, overturned that punitive text and said states could not be so compelled.

Eighteen states, all Republican- led ones, have chosen not to expand Medicaid.

And now the House bill presumes to phase out Medicaid expansion altogether.

Obviously, Medicaid expansion needs to be continued and new forms of incentives— rather than punishments— need to be extended to lure those 18 states.

A decent model for that is being pursued by Arkansas— in Gov. Asa Hutchinson’s seeking conservatizing waivers to allow states to determine the eligibility of their own expansion populations, impose a work requirement on that population, and require some reasonably small premium contribution by recipients.

I’d like to see every state do as Arkansas has done in using the Medicaid expansion money to buy private policies for recipients and thus dump that money into the pool for everyone.

That would require bipartisanship in which the more liberal- minded would accept restrictions on Medicaid expansion and privatization. It would require the more conservativeminded to accept Medicaid expansion.

That kind of compromise is how government must work, and has worked, and could still work. It’s called putting the country ahead of party.

The serious solution on covering pre- existing conditions and expensive diseases is a reality- based variation of what the House Republicans put in their horrible bill.

What House Republicans provided was that states could seek waivers to define pre- existing conditions their own way and move those afflicted people into high- risk pools presumably endowed by public funds from federal and state governments.

The failings of that have to do with the vagaries of state governments and the absence of reasonable assurances that at least some people with expensive diseases wouldn’t be denied affordable coverage.

Here we could use a binding federal solution. And we also could use those added federal dollars for “Healthcare” to which the madly tweeting president referred.

All persons with pre- existing conditions as strictly defined and nationally uniform should be allowed to buy on the exchanges from the same menu of policies available to everyone. They should pay the same premiums as everyone else.

But the acknowledged and often catastrophic additional expense of their care should be paid by a federal government risk pool in the form of strictly regulated premium supplements to private insurers.

Yes, I’m saying that all of us, collectively, should cover the premium gaps for the most chronically and gravely ill— gaps between what all of us pay for health insurance and the costs they incur for the sin of being expensively sick.

I can think of no more appropriate purpose for our taxes than to keep our sickest people from being denied care, or going bankrupt, or burdening our general health- insurance pool with such exorbitant costs that everyone’s premiums become unsustainably expensive.

Getting those costs down is a second and even- tougher policy frontier after we get everyone covered.

A conservative radio talk- show host was scoffing the other day that we owe no obligation to some guy who is dying of lung cancer after smoking three packs of cigarettes every day for an adult lifetime. I admit those dollars would be spent grudgingly. But to deny that man coverage for chemotherapy or radiation and then for morphine for pain at the end …. that’s not who we are.

Those would be the real “death panels” that the Trumpianly absurd Sarah Palin railed against.

I thought conservatives were prolife. More likely they are pro- life for the innocent, except for those innocently born into cycles of poverty and cultural deprivation and for whom they would reduce food stamps and Medicaid.

So maybe what they are is probirth, and pro- neglect thereafter.

There are Republicans less extreme than that. They are the vital and potentially heroic ones who could work with the less- extreme and potentially heroic Democrats to fashion something resembling what has been described here, and surely better.

As Ohio Gov. John Kasich has said, strictly partisan passage of Obamacare and strictly partisan repeal of Obamacare amounts to a cycle that gets us nowhere except on dysfunction’s seesaw.

Oh, and the obvious postscript: A solution would be single- payer government insurance, with all of us moving into a premium- charging Medicare for all. But I’m trying to be ambitious, not utopian.

John Brummett, whose column appears regularly in the Arkansas Democrat- Gazette, was inducted into the Arkansas Writers’ Hall of Fame in 2014. Email him at jbrummett@arkansasonline.com. Read his @johnbrummett Twitter feed.