Thursday, May 11, 2017

Trumpcare, Part II -- the Perils of Politics Divorced from Policy

Here's my assessment of the content and political prospects of the second attempt at Trumpcare, and some thoughts about how we got to this point and where we go next.

The Bad

The bad news is that the recently-passed House bill is an abomination. As Paul Krugman points out, in the process of trying to fulfill the political goal of doing away with Obamacare, the bill shatters all Donald Trump's promises relating to affordable coverage for everyone. This version likely would take an even higher human and economic toll than their earlier attempt, which would have left 24 million people without health insurance, yet House Speaker Paul Ryan rushed the bill through before the nonpartisan Congressional Budget Office could quantify the damage. This bill got rushed through not in spite of how awful it is, but because of how awful it is. I am not sure how much lower the bar for what counts as legislating can possibly get, but I no longer underestimate Paul Ryan's capacity to outdo himself.

The Good

The good news is that this bill will never become law. Thankfully, there are reasonable Republicans in the Senate who already have panned the House bill and said they would start from scratch. It will be interesting to see their proposal. Unlike their House colleagues, they are likely to make a serious effort to produce coherent legislation, but at the end of the day their efforts probably won't matter. Unless they can craft a bill that garners significant Democratic support, which at this point seems unlikely, any bill that can pass the Senate stands little hope of passing the House and vice versa. Even if the Senate were to craft a broadly-supported bipartisan alternative, there is a good chance that opposition from the far-right Freedom Caucus, to which Paul Ryan has given disproportionate power, nonetheless could doom its fate. Right now, therefore, it looks as if a health care overhaul won't happen in this Congress. As discussed below, however, there is glimmer of hope for more modest reform.

The Ugly

Congressional inaction, while better than enacting an incoherent and broadly harmful law, nonetheless does a gross disservice to the American people. Obamacare -- which, lest we forget, has some clear roots in a Heritage Foundation proposal and a plan Mitt Romney implemented in Massachusetts -- is a reasonable start at reforming a flawed market-based insurance system. But, it has its own problems, which appear to be getting worse. Responsible policy makers would address those problems. Instead, if Donald Trump & Co. fail to either enact their own version of health care reform or fix the existing law when they control both houses of Congress and the presidency, they will continue sabotaging Obamacare so they can try to blame the Democrats instead of themselves for the unacceptable results of their ineptitude. Unless the Democrats overcome their own ineptitude regarding messaging and spin, this blame-shifting exercise might well succeed.

The Potential for Greater Good

A possible silver lining is that if the House bill or something comparably bad actually passes or if we are left with a severely hobbled version of the status quo, then that might prompt a move toward the single-payer solution that virtually every other wealthy industrialized country in the world has managed to implement successfully. That seems unlikely in the near term because the visceral negative reaction to single-payer runs so high, but it is interesting that people on both sides of the political divide are now discussing the possibility. For more about this, I refer you to right-leaning columnist Charles Krauthammer and left-leaning columnist Eugene Robinson, each of whom have speculated about why and how a pivot to single-payer could happen.

The Explanation

As with most political matters, the explanation of how we got here is multifaceted. One of the recurrent themes, however, is that the politics of health care reform have become completely divorced from any coherent policy vision relating to that topic. The primary reason for that, in turn, is the inability of the Republicans to agree internally about what their policy vision should be. 

While promising to repeal Obamacare for over seven years, the Republicans were never forced to articulate a policy vision of their post-Obamacare world. Sure, they talked in broad terms about getting government out of people's health care and a free market system, but they never explained what their free-market alternative would entail, the mechanics of undoing Obamacare, or how people's lives would be affected. Secure in the knowledge that their repeal efforts would not succeed, their talk was an easy way to fuel anti-Obamacare furor and reap short-term political gains. Repealing Obamacare was a purely political goal untethered to any concrete policy vision.

Then along came Donald Trump. First was his laughably content-free promise to repeal Obamacare and replace it with "something terrific." This eventually was followed by a promise to repeal and replace with "[health] insurance for everybody" that would result in "great health care" that is "much less expensive and much better." This notion of universal, affordable health insurance coupled with better health care actually passes muster as a concrete policy goal, albeit incomplete as a total policy vision because he gave us no clue about how he planned to achieve the stated goal.

There are some congressional Republicans, particularly from states that benefited from Obamacare's Medicaid expansion, who agree with some version of Mr. Trump's universal coverage goal. In light of their limited government principles, there's only so far they'll go in terms of government involvement to achieve that goal. Nonetheless, this group seems inclined toward expanding or at a minimum preserving coverage, and has clearly signaled they won't support a bill that takes coverage away.

This is directly at odds with the Ayn Rand free marketers such as Paul Ryan and the anti-government Tea Party and Freedom Caucus members. They want to significantly reduce, or ideally eliminate, the government's role in health care and let an unfettered free market work its will. That this would result in millions of people losing coverage or paying far more to maintain it is seemingly irrelevant to them.

The fact that the Republicans have been of two minds about health care policy remained hidden beneath the surface of their united, but ultimately empty, "Repeal Obamacare" sloganeering. When their party won the presidency and majorities in both houses of Congresses, however, their bluff was called and they were forced to act.

How the House leadership has chosen to act has been telling, and not in a good way. They neither tried to translate Mr. Trump's promise of affordable health care for everybody into reality nor attempted to craft a solution that satisfied their pure free market tendencies. Nor did they sit down and think about ways in which they might be able to advance these apparently conflicting goals simultaneously (maybe because one obvious answer to that is "Obamacare"-- more about that below).

Instead of coalescing around an articulated policy goal as a starting point, Paul Ryan and Donald Trump decided that passing something, anything, that could be labeled as undoing Obamacare was an end unto itself, and Mr. Ryan reverse-engineered the content of the bill to achieve that goal. In the process, he revealed that he will do whatever it takes to appease the Freedom Caucus, which is a mistake that will haunt him for the remainder of his speakership. The sad but predictable result is an incoherent bill that doesn't even pretend to advance the public interest.

Even people who hate Obamacare because they are affected by its shortcomings would rightly be appalled by this callous disregard for basic principles of governing. Indeed, they especially should be appalled, because if this bill by some miracle became law it almost certainly would make them worse off. Even if this bill dies in the Senate, the electorate should not forget that a majority of the House of Representatives -- the "People's House" -- was willing to vote for a political end unattached to any coherent policy goal relating to their constituents' physical and economic well-being.

What Should the Goal Be?

Until the Republicans either choose which of their two competing policy goals to unite behind or somehow find a way to reconcile those goals, their legislative efforts are going to stall. So which goal is the better one?

I am far more sympathetic to Mr. Trump's stated goal (something I never thought I'd write), for two reasons. First, the health care market prior to Obamacare, to which Mr. Ryan apparently wishes to return, was never really a free market. It was rigged by the insurance companies, working in coordination with mainstream medical providers, and when people without coverage got sick or injured and couldn't afford their care under that system the rest of us bore the cost. Second, even if the pre-Obamacare system really had been a well-functioning free market, so what? Health insurance and health care services are not like widgets that can be allocated solely based on market forces of supply, demand, and ability to pay.

I might or might not want a widget, and if I want one I might or might not be able to afford it, and that is all fine. Health care, by contrast, is a basic need we all share to varying degrees, and our individual demands are largely unpredictable and in many cases not a matter of choice. Nobody asks to have a catastrophic illness or injury. Yes, some of us face, or voluntarily take, more risks than others. Nonetheless, the reality is that each of us, no matter how healthy we might seem, is continually at risk of getting sick or injured and needing medical services. In addition, many people need preventive services that aim to improve overall health or reduce specific risks.

When the inevitable need for health care arises, how many of us honestly think that a person's medical fate, perhaps even their life, should depend primarily on a combination of how rich they are and where they live? I sincerely hope that the vast majority of my fellow Americans do not think that. Even if you do believe in a total free market system in which the rich fare better than poor, remember this: until hospitals are allowed to turn people away, the costs of leaving people un- or under-insured still will be borne by the rich. The fundamental question isn't whether the rich subsidize the poor, but rather through what mechanism that subsidy occurs. 

A Case for Obamacare Reform

I am hopeful that a majority of Americans are coalescing around the goal of affordable health care as a basic right, and thus a valid reason for federal government involvement. If that is the case, then the existing Obamacare law is good starting point for reform. Interestingly, Obamacare also is a good starting point for reform for free market proponents who don't embrace the universal coverage goal.

The genius of Obamacare, and Romneycare before it, and the Heritage Foundation paper before that, is that they offer something for liberals and conservatives alike to embrace. There is the goal of universal coverage that liberals like, but that goal is achieved by improving the existing health insurance and health care service markets and using market-based mechanisms and incentives, which should appeal to conservatives. Right now, Obamacare is not doing a good enough job on either the coverage goal or the market-propelled execution, and that, I believe, should be the focus of any reform. Policy experts have been looking at these issues since Obamacare became law. We, and our representatives in Congress, would do well to solicit, listen to, and think critically about the solutions they propose.

Fixing Obamacare would require congressional Republicans to admit they mischaracterized the law all along and renege on their long-standing promise to kill it, which would appear to doom this as an option. But maybe, just maybe, those crafty Republicans will fix Obamacare after all, only they'll repackage and rename the law and pretend that's not really what they're doing and hope the rest of us don't notice. That, really, is the only viable reform path I see at this stage, and history has shown that the Republicans have the capacity to pull off something like this.


Although I don't hold out a whole lot of hope for sensible health insurance reform in the near term, I still think it is an issue worth examining and debating, because eventually its time will come. I urge you to examine what you believe about health care and why, and what the logical consequences of your preferred belief would be for health-related markets and human well-being. If you disagree with my views, I welcome your explanation as to why and hope we can have a constructive discussion. Who knows, maybe the best answer is something no one has thought up yet because the various camps continue to talk past, instead of to, one another.

The other thing I would suggest is that once you identity your preferred goal, tell your elected representatives. Our representatives and senators do after all work for us, and we must hold them accountable. At a minimum, we must tell them that legislating with no coherent policy vision on a topic that concerns every American is unacceptable.

* The views and opinions expressed in this blog post are solely those of the author.

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