Re­peal and re­place? In­stead, tweak and move on

The Denver Post - - PERSPECTIVE - By Ge­orge F. Will

Two Junes ago, when the Supreme Court up­held, 6-3, a chal­lenged pro­vi­sion of the Af­ford­able Care Act, Chief Jus­tice John Roberts, writ­ing for the ma­jor­ity, vented: “Congress wrote key parts of the Act be­hind closed doors. … Congress passed much of the Act us­ing a com­pli­cated bud­getary pro­ce­dure known as ‘rec­on­cil­i­a­tion,’ which lim­ited op­por­tu­ni­ties for de­bate and amend­ment, and by­passed the Se­nate’s nor­mal 60-vote fil­i­buster re­quire­ment. … As a re­sult, the Act does not re­flect the type of care and de­lib­er­a­tion that one might ex­pect of such sig­nif­i­cant leg­is­la­tion.” Now, how­ever, Repub­li­cans run things, so …

In 2009, Pres­i­dent Obama ig­nited a de­bate that has been, for many mem­bers of Congress and their con­stituents, em­bar­rass­ingly clar­i­fy­ing. Back then, most peo­ple stoutly in­sisted that they did not want a “gov­ern­ment-cen­tered” health care sys­tem. But even then, ap­prox­i­mately half of ev­ery dol­lar spent on health care came from the gov­ern­ment. To­day, the 55 mil­lion Medi­care ben­e­fi­cia­ries ap­prox­i­mately equal the com­bined pop­u­la­tions of 26 states; the 73 mil­lion Med­i­caid re­cip­i­ents ap­prox­i­mately equal the com­bined pop­u­la­tions of 29 states. Gov­ern­ment’s 10 thumbs are all over health care.

Al­though an Atlanta Journal-Con­sti­tu­tion poll showed that health care was “ex­tremely” or “very” im­por­tant to 81 per­cent of vot­ers in the re­cent Georgia con­gres­sional elec­tion, nei­ther can­di­date stressed this is­sue. Both were con­fronted, as all con­gres­sional can­di­dates will be in 2018 and ever after, with this fact: No health care pol­icy is com­pre­hen­sive, com­pre­hen­si­ble and in­of­fen­sive to all in­tense groups.

Health care only rel­a­tively re­cently be­came worth fight­ing over. In 1900, Amer­i­cans spent al­most twice as much on fu­ner­als as on medicine. Most peo­ple were born at home and died at home, and medicine’s prin­ci­pal func­tion was to make ill peo­ple as com­fort­able as pos­si­ble while na­ture healed them or killed them. Hos­pi­tals of­ten were lethal in­fec­tion fac­to­ries, hence the com­mon re­port, “The op­er­a­tion was suc­cess­ful but the pa­tient died.” In his “The Rise and Fall of Amer­i­can Growth,” Robert Gor­don notes that “even vic­tims of rail­road, street­car and horse cart ac­ci­dents were largely taken to their homes rather than to hos­pi­tals.” In 1900, only 5 per­cent of Amer­i­can women gave birth in hos­pi­tals. And “a ‘de­gree’ in medicine could be ob­tained for be­tween $5 and $10, its cost de­pend­ing on the qual­ity of the pa­per on which the diploma was printed.” Be­tween 1890 and 1950, the great im­prove­ment in mor­tal­ity rates owed much to so­cial im­prove­ments (bet­ter hy­giene, san­i­ta­tion, food han­dling, etc.) and lit­tle to doc­tors, hos­pi­tals or drugs.

In 2009, there was no na­tional con­sen­sus that in­sur­ance should be avail­able to peo­ple with “pre-ex­ist­ing con­di­tions.” There now is such a con­sen­sus, partly be­cause of the ob­fus­cat­ing phrase: In­sur­ing peo­ple with “pre-ex­ist­ing con­di­tions” means in­sur­ing peo­ple who are al­ready sick. Which means that what they are get­ting is not re­ally in­sur­ance — pro­tec­tion against un­cer­tain risk. The con­sen­sus might be right, but its logic makes the in­sur­ance model in­creas­ingly in­ap­po­site.

A mar­ket-driven health care sys­tem with gov­ern­ment at the pe­riph­ery would im­ple­ment the les­son of So­cial Se­cu­rity: Gov­ern­ment is good at send­ing checks to iden­ti­fi­able co­horts. It should send sup­port to those who need it for pur­chas­ing pre­mi­ums, then get out of the way.

But Obama, who once said he pre­ferred a sin­gle-payer sys­tem, flinched from the re­ally rad­i­cal re­form we need — a move away from broad re­liance (about 180 mil­lion Amer­i­cans) on em­ployer-pro­vided health in­sur­ance, which, in an ex­pen­sive fic­tion, is not taxed as what it ob­vi­ously is: com­pen­sa­tion. Partly be­cause of this sys­tem, health care con­sumers are not shop­pers and mar­ket sig­nals are weak and few.

Sup­pose that in­stead of pro­vid­ing health in­sur­ance, em­ploy­ers gave em­ploy­ees money to buy gro­ceries. What would gro­cery stores look like? There prob­a­bly would be no prices. To see why, ask your­self: When your doc­tor wants to per­form a par­tic­u­lar test, do you ask, “How much will it cost?” If you do, you are ec­cen­tric. Be­sides, the doc­tor prob­a­bly does not know.

Per­haps for pol­icy rea­sons, and cer­tainly for po­lit­i­cal rea­sons, it is im­pos­si­ble to un­wind re­liance on em­ployer-pro­vided in­sur­ance. But this fact, com­bined with the “pre-ex­ist­ing con­di­tions” con­sen­sus, means that hence­forth the health care de­bate will be about not whether there will be a thick fab­ric of gov­ern­ment sub­si­dies, man­dates and reg­u­la­tions, but about which party will weave the fab­ric.

So, “re­peal and re­place” will be “tweak and move on.” And even if the tweaks con­sti­tute sig­nif­i­cant im­prove­ments, Obama will have been proved right when, last Oc­to­ber, he com­pared the ACA to a “starter home.” E-mail Ge­orge F. Will at georgewill@wash­post.com.

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