Republicans can hardly believe their good luck.
The Obama administration has once again snatched defeat from the jaws of victory. After successfully holding off Republican efforts to destroy “Obamacare” by shutting down the government and threatening default, the administration badly bungled the rollout of the crown jewel of health reform: the insurance exchanges. (No surprise to those of us who wrestle with computers daily.)
Somehow administration leaders also failed to anticipate the predictable response of insurance companies to a perfect opportunity to raise premiums wholesale, while blaming someone else.
Nevertheless, we need to keep in mind that even as they gleefully tear into the ACA, Republicans have not offered an alternative.
On reflection, however, this is no surprise. Republicans don’t see a problem with health care in America. Insurers can sell what they chose to whom they chose; people can select policies they like and can afford, or save their money for other things. This is how markets work. The only change Republicans would make is deregulation, so insurers and good prospects can find one another more easily across state lines.
As Ronald Reagan said: “Government is not the solution to the problem, government (in this case, the ACA) is the problem.”
For conservatives, health insurance and health care are ordinary commodities to be traded in the marketplace, just like automobile insurance and automobiles.
But health care is not just another item in the shopping cart. As the African-American spiritual observed, “If living were something that money could buy, the rich would live and the poor would die.”
And that is where we are in the 21st century. Health care is a matter of life and death. Our medicine is highly effective. Today, we can cure, or treat, diseases that were once fatal — heart attacks, many cancers, even HIV. That is, if you have the money. Today rich Americans live, on average, five years longer than poor citizens.
Nor is health insurance an ordinary insurance product.
Illness today is not evenly distributed across the population. Some 10 percent of people are responsible for 60 percent of health care costs in the United States. Because most illness continues for many years after diagnosis, these people are easy to identify: patients with multiple sclerosis, congestive heart failure, lymphoma.
No one wants to pay for the sick people — not the insurance companies (particularly if they cannot recover their costs by charging the sick higher premiums), and not healthy customers. We hear this now, as single men and older people complain that to comply with the ACA, they have to pay for maternity benefits that they will never use.
A free market with lots of choices among multiple insurers, risk pools, policies with all sorts of benefits and price structures, allows insurers and healthy individuals to avoid the sick. The less affluent healthy can gamble on inexpensive policies with spotty coverage (useless to the chronically ill): Since most people are healthy most of the time, few of them will ever need to test their insurance. (Or they can join large groups of other healthy people working for large employers who provide insurance.) Insurers can charge sick people thousands of dollars a month to cover the cost of their claims, and then some.
The result? The people who need health care the most have the most difficulty getting insurance that covers it. Doesn’t this defeat the whole purpose of the exercise?
That, however, is the Republican alternative to the ACA. And remember, even before the ACA, things were not stable, but deteriorating: As health costs rose, premiums, co-pays and deductibles were going up, employers were cutting back. Without the ACA, those trends will continue.
The ACA was an effort to preserve a private health insurance market, using regulation to achieve a better result. As we see, this is very complicated.
There is a third option. If everyone is in the same, large, pool, everything medically necessary is covered, insurers are paid merely to process claims, and premiums are scaled to income, there is enough money to cover everyone at reasonable cost without elaborate, expensive, error-prone computer programs and geniuses to run them. People will be able to choose their doctors and hospitals. (And the rich can always buy more if they want.)
A crazy, wild-eyed socialist nightmare? No, this is Medicare, a familiar, popular, competently-run public insurance system that everyone’s parents or grandparents rely on. Person-for-person, disease-for-disease, Medicare is the cheapest, most efficient health insurance program in the country. (There is virtue in simplicity.) Medicare already controls health care costs better than private insurers, and with a few tweaks, could do much more, forcing prices down to the level citizens of every other advanced democracy pay, with no sacrifice in quality.
Given the alternatives, maybe Medicare-for-all deserves a second look.