Thursday, April 6, 2017

Political Healthcarre

“Who knew that healthcare could be so hard?” mused President Trump a few weeks back. Who knew? Probably anyone who has paid attention to this topic the last eight years. Apparently the President has not paid attention, and had to get his education crammed into three weeks.

People talk about healthcare a lot. But in actuality what they are usually talking about has little to do with the actual provision and receiving of good health practices. Rather, what they are really talking about is political advantage and power, and using healthcare as the hostage issue. The political arguing continues unendingly, and the fiasco of the recent House “repeal and replace” effort shows how badly the politics are souring the discussion.

In 2009-2010, the Democrats controlled the House, Senate and Presidency. They still needed a full year to fulfill Obama’s campaign promise to expand and improve healthcare delivery. It took intense bargaining to get something agreeable even to one Party in political control. In the end, it passed without a single affirmative Republican vote, and cost more than a few Democrats their Congressional seat. Those Republicans on the sideline then took up the chant of “Repeal Obamacare” as part of their “anti-everything-Obama” strategy for the next six years, with the House voting over 60 times for repeal. It was always a safe vote to score points with their base, knowing that each resolution would be vetoed by Obama. But during all of those votes, not once was a credible alternative offered for Obamacare. It is easy to just vote NO when you do not have to come up with a solution.

But a funny thing happened. In November 2016 Republicans won the House and Senate, and brought in a President who said on the campaign trail he would repeal Obamacare and replace it with “something better” so that “everyone would get healthcare.” It was all going to happen on “Day 1,” given that Republicans had had six years to come up with this replacement. Six weeks after Inauguration Day, House leaders finally unveiled their legislative masterpiece. Drafted in secret, devoid of advance consensus support, nobody – except Trump and the leaders – liked it. Democrats sat on their hands, uninvited to the discussion, with memories of the Republicans in 2010 still fresh, and said, “show us what you’ve got.” What Republicans had got was not much. For some, the Repeal side didn’t go far enough. For others, it took away too much. Ditto the Replacement side. Every major health organization came out against it: doctors, hospitals, pharmaceuticals, patient groups, AARP, etc. Even the Senate said the bill was dead-on-arrival. When the Congressional Budget Office said 24M people would lose insurance, and federal spending would be reduced only modestly over ten years, the oxygen went out of the Capitol.

Along the way, another funny thing happened. The politicians found out that, over time, much of the public had become quite fond of the new health services they were getting – as long as it was not called “Obamacare.” A large number of uninsured people now had coverage. People with preexisting conditions could no longer be denied and did not need to stay tethered to unsatisfying jobs. Expanded services were welcomed; poor people were getting medical care. The destruction of American life and the healthcare industry did not occur. Tellingly, only 17% of the public supported the Republican Repeal and Replace bill, and a newfound majority actually expressed approval of the dreaded Obamacare. Times had changed.

Nevertheless, House leaders and Trump soldiered on. What took Democrats 12 months of contentious debate to do, Republicans thought they could do in only 17 days. In the beginning, Speaker Ryan said, “This is what we’ve got,” and Trump the Dealmaker tried the schmooze approach to get it passed. When that did not work, Ryan negotiated away the heart of his bill, and Trump resorted to the usual threats and insults toward the intra-Party opposition. None of it worked, and the bill never came to a vote. Everyone just gave up and walked away. The Art of the Deal folded.

The Republican bill was always driven more by a goal to quickly fulfill a six-year campaign pledge to their base than actually improving healthcare delivery. Reducing such an important issue to political theatrics deservedly died in infancy. Repeal is easy. Just revoke the laws of the last eight years and take everyone back to the “good old days” – which were not very good. But Replace gets very hard, because it begs the still unanswered question: what should a common baseline of healthcare services and delivery look like across America?

Trump and Republicans have long proclaimed Obamacare to be a “disaster,” without proof. Setting aside the “Chicken Littles,” in fact it works just fine in many parts of America. Around half of the states (including Republican strongholds) have adopted Medicaid expansion – but not all. Most Americans have multiple insurance programs to choose from – but not all. Premiums have gone down for many Americans – but not all. Coverage is now available to many who did not have it – but not all. Insuree rights have been strengthened – for all. But the prices of drugs and hospital stays are still too costly, affecting costs for everyone.

Some politicians look to private enterprise for a solution. Lest we forget, insurance companies and medical professionals have had at least 60 years to meet the public’s needs, and failed. Why would we assume they will achieve it now? If we really want to relieve corporations and businesses of their Obamacare problem, we should just eliminate company-provided health insurance all-together. Employer-provided health insurance is a stupid system in the first place, effectively requiring the public to have a job in order to have insurance coverage, provided by businesspeople who know nothing about the subject and which has nothing to do with their core business. Get corporate America out of a middleman role and we will immediately start off with a simpler system. Create a standardized administrative system for processing healthcare; we are drowning under the costs of multiple unique yet redundant systems/forms/regulations. Make all medical charges public so people can see ahead of time what services will cost; the whole system still operates under a veil of secrecy.

If you do not want to “force” people to buy health insurance, then are you willing to let health providers turn sick people away when the uninsured get sick or have an accident? Emergency Rooms are still the most expensive and inefficient providers of primary care. Would you rather tax me to underwrite their insurance premiums, or make me pay higher costs for my services to underwrite the Emergency Room costs? Either way, I pay. Should I? Debate the question.

If one is really serious about healthcare in America, these are the kind of discussions we should be having. Discussions about getting and keeping Americans healthy, not political slogans, campaign rhetoric, and ill-thought out plans. Otherwise, just move on to something easier. Like tax reform (right!). Who knew it could be so hard?

©   2017   Randy Bell