Re­peal and re­place isn’t dead yet

Modern Healthcare - - COMMENT - MER­RILL GOOZNER Edi­tor Emer­i­tus

Don’t kid your­self. We haven’t heard the last of re­peal­ing and re­plac­ing Oba­macare.

The GOP’s lat­est at­tempt to un­der­mine the law failed be­cause three Repub­li­cans, the bare min­i­mum, had enough sense to op­pose leg­is­la­tion that would cre­ate chaos through­out one-sixth of the U.S. econ­omy. The Gra­ham-Cas­sidy bill would have given every state just two years to com­pletely re­vamp their Med­i­caid pro­grams and in­di­vid­ual in­sur­ance mar­kets with an es­ti­mated $1 tril­lion less money over the next decade.

Ac­cord­ing to the best avail­able es­ti­mates (the usu­ally reliable Con­gres­sional Bud­get Of­fice could only give di­rec­tional es­ti­mates for what 50 state leg­is­la­tures might do), tens of mil­lions of Amer­i­cans would have lost in­sur­ance cover­age. Hun­dreds of thou­sands of health­care work­ers would have lost their jobs. In states with GOP-con­trolled state­houses (Repub­li­cans now have 33 gov­er­nors and con­trol 32 leg­is­la­tures), in­sur­ance com­pa­nies would have be­come largely dereg­u­lated. Peo­ple with pre-ex­ist­ing con­di­tions in many of those states would get slapped with soar­ing rates. Bare-bones cover­age with huge out-of-pocket ex­penses would be­come the norm in many re­gions.

De­spite protests from or­ga­ni­za­tions rep­re­sent­ing every ma­jor health­care con­stituency, each GOP sen­a­tor save three were will­ing to sign on to the bill.

As soon as Se­nate Ma­jor­ity Leader Mitch McCon­nell ad­mit­ted de­feat for a sec­ond time, the bill’s ar­chi­tects vowed to at­tach it to the bud­get bill that must be ap­proved to avoid a gov­ern­ment shut­down. Con­ser­va­tive hard­lin­ers took to the air­waves to call on the Trump ad­min­is­tra­tion to cut off its mon­thto-month sup­port of the cost-shar­ing sub­si­dies that al­low in­sur­ers to lower out-of-pocket ex­penses for the poor­est Amer­i­cans who buy exchange plans.

Given the fun­da­men­tally con­ser­va­tive na­ture of Oba­macare—it re­lied on pri­vate in­sur­ers and Med­i­caid to ex­pand cover­age, not sin­gle-payer or other more rad­i­cal mea­sures—one has to ask why the GOP re­mains fix­ated on de­stroy­ing some­thing that has worked fairly well. The unin­sured rate is in sin­gle dig­its; and over­all health­care spend­ing, ris­ing at its slow­est pace since the 1990s, en­abled the gov­ern­ment to spend nearly half a tril­lion dol­lars less than orig­i­nally ex­pected on Medi­care, Med­i­caid and sub­si­dies for the unin­sured.

The easy an­swer is that it is all about the in­creas­ingly nasty in­fight­ing on the GOP right. You can’t scream “re­peal and re­place” for seven years and then fail to de­liver.

But some­thing deeper is at work. In a must-read ar­ti­cle in the lat­est New Yorker, Dr. Atul Gawande re­turned to his na­tive Athens, Ohio, a col­lege town on the edge of Ap­palachia, to talk about health re­form with lo­cal res­i­dents. He provoca­tively be­gan with this ques­tion: “Is health­care a right?”

Many of the peo­ple he spoke with had se­ri­ous health­care needs. Those with em­ployer-pro­vided health in­sur­ance strug­gled to pay their co­pays and de­ductibles. They re­peat­edly de­nounced peo­ple on Med­i­caid, say­ing they “just don’t work. They’re lazy.”

The idea that Med­i­caid is filled with able-bod­ied peo­ple un­will­ing to work has be­come a sta­ple of the cur­rent health­care debate. Yet, be­fore the Med­i­caid ex­pan­sion, less than 20% of peo­ple on Med­i­caid were able-bod­ied adults, nei­ther aged or dis­abled.

Gawande notes near the end of his ar­ti­cle that “the ACA post­poned reck­on­ing with our gen­er­a­tions-old er­ror of yok­ing health­care to our jobs—an er­ror that has made it dis­as­trously dif­fi­cult to dis­ci­pline costs and in­sure (sic) qual­ity, while sev­er­ing care from our foun­da­tional agree­ment that, when it comes to the most ba­sic needs and bur­dens of life and lib­erty, all lives have equal worth.

“The prospects and costs for health­care in Amer­ica still vary wildly, and in­com­pre­hen­si­bly, ac­cord­ing to your job, your state, your age, your in­come, your mar­i­tal sta­tus, your gen­der and your med­i­cal his­tory,” he wrote.

As long as that’s the case, un­scrupu­lous politi­cians will be able to ex­ploit the re­sent­ments those in­equities breed, and pit one group of Amer­i­cans against an­other for their own elec­toral ad­van­tage. Gra­ham-Cas­sidy may be dead, but re­peal and re­place lives on.

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