Whither Healthcare?

“Now, I have to tell you, it’s an unbelievably complex subject. Nobody knew health care could be so complicated.”  — President Donald Trump 27 February 2017

And you know what?  He is correct.

As the Senate debates and votes on Trumpcare to repeal and replace Obamacare over the coming days, much will be written and talked about regarding its impact and efficacy.  Some will think it is great and others will think it a travesty.  It all depends on what the goal for the program might be and how one thinks that goal should be attained.  Is Trumpcare, or the American Health Care Act (AHCA) (as it is called in the House of Representatives while the Senate Bill is called the Better Care Reconciliation Act of 2017) designed to help Americans and keep them healthy or is it an attempt to do the bare minimum while saving the government, and ultimately tax payers, money?  One’s view of Trumpcare also depends on whether or not Obamacare, or the Affordable Care Act (ACA), is working for you.

Put more succinctly, is healthcare in the greatest country on earth a right or a privilege?  Should it be open to a free market — those that can afford to pay do, those that can’t need to earn more money — or something that every citizen deserves?  If you happen to think that healthcare is a privilege, you get what you pay for, then you may as well stop reading here because you basically think that the government should have nothing to do with healthcare.  If you think that access to healthcare should be a right, then read on. Be forewarned however, that this is, as the president says, complex. Politicians of every stripe also parse and obfuscate elements of healthcare to their own advantage. It can be difficult to determine where the truth lies — especially since many times two people can both be technically correct while interpreting the meaning in totally different ways.  As I like to say, it is the difference between what things are and what things mean.

Here is the crux of the problem.  The United States does not suffer from poor medical care.  People come from all over the world to have their health problems resolved here in the U.S. — if they can afford it. That is the problem.  It is not the quality of care, but rather having access to good care and being able to afford it. Access and affordability are the reason we need insurance plans which is what both Trumpcare and Obamacare are really about.

The U.S. does not really have a health system.  It has a series of health systems depending on whether the individual is on Medicaid or Medicare (the dreaded by conservatives single payer system), or on the VA or Tricare (military) system (basically socialized medicine), or gets insurance through an employer (where most people get their insurance), or buys it on the open market (usually very expensive).

A pervasive goal in the U.S. should be that no one goes bankrupt due to an unexpected illness or injury. Likewise no one should have to forgo medical treatment because they cannot afford it.  Both happen in the U.S., although by most accounts, Obamacare went a long way in reducing the numbers of people in either situation.

So let’s design a system that helps people get care without using their every last dollar.  Let’s assume we want a system where no one can be turned down — or charged unattainable amounts of money — for a pre-existing condition.  This seems to be one area that most politicians can agree upon and one of the most popular aspects of Obamacare.  How to do that?  It does not take a genius to see that maybe I won’t buy any insurance until I get sick or injured and I will save a lot of money in the meantime.  That leaves only those with pre-existing conditions on the insurance rolls — a situation which will either leave the premiums so high as to be unaffordable, or leave the insurance companies holding the bag and going bankrupt.  To even out the costs and make them more affordable to all, we would then require everyone to have insurance — the dreaded mandate. However, it may not be fair or even affordable for everyone to buy insurance, especially for people that do not receive insurance through their employer, so if we are going to require it, then we should come up with a system to help people pay for it — the other debated aspect, subsidies. Those three elements are the basis for every proposed health care plan concocted by politicians.  If you play around with one of the three, it impacts the other two.  It becomes a very complicated game.  How one plays the game depends on my opening statement — what is the goal for the plan?

On top of that throw in hot button issues such as who can do what (Planned Parenthood anyone?), whether in our proposed system we “punish” young healthy citizens by making them subsidize the old “sick” citizens, should the government have the power to tell people that they “have” to have insurance, and who pays for all this, the wealthy or the poor who are most likely to benefit from a plan like this.  It does indeed get complicated in a hurry, and also very emotional for a lot of people.

In evaluating a planned system, lots of politicians focus on premiums and deductibles — and not always together.  It is possible to devise a plan with very low premiums, lower than Obamacare, but does it cover everything?  Does it have a high deductible?  Does it have annual or lifetime caps? What pre-existing conditions are covered?  Those and other details mute any discussion about premiums.  To coin a phrase, we cannot compare apples with oranges.  Premiums are certainly relevant when discussing the cost of a particular plan, but it is not sufficient to get a true picture of the impact or value of that plan.

To muddy the issue, the president makes unfounded claims about Obamacare.  He says “it is dead.” Except it isn’t.  But the president and the Republican leadership are trying hard to kill it, partly to force through Trumpcare.  Insurance exchanges are drying up and companies are pulling out because of the biggest fear they have — uncertainty.  The Congress has yet to decide if they will provide the money for the aforementioned subsidies to help people afford the mandated insurance.  And they have announced that they will not enforce the mandate.  Two of the legs of our three-legged plan are being distorted, that means the third leg is terribly out of balance which makes it appear the system is not working.  If insurance companies don’t think they are going to get paid — or that they will be left holding the bag for high cost pre-existing conditions which they are required to cover — then there are two choices.  They can raise premiums or leave the market.  Most experts assert that without the uncertainty coming from the White House and Capital Hill, the health insurance system in the U.S. would be stable and hold down costs for most (most — not all) Americans seeking health care.  Many people now have insurance that would not otherwise have it.  The result is “wellness checks” and other preventive health measures now sought out by people that did not seek it before.  Therefore they are healthier and the over all expenditures for larger, more catastrophic care comes down because they are less necessary.  Like it or not, the states that expanded Medicaid under Obamacare generally have more small hospitals and clinics serving the poor or rural areas of their states because those hospitals have a known source of income for the care they provide.  Many of those small hospitals and clinics closed in states that did not expand Medicaid and there is significant concern over the reduction of those Medicaid funds under Trumpcare. In mostly rural states such as Alaska and Maine, even their Republican Senators are concerned and may vote against the proposed Senate bill.  Senators Murkowski and Collins both realize what the proposed reductions in Medicaid mean to their states and are worried, as are others.

Whatever your own views on healthcare in the U.S. take a good hard look at any plan floated to solve the problem.  I am no expert on this subject.  Not at all.  I recognize that we do not have a bottomless purse to pay increasing costs for social programs.  I get it.  Personally, I think we leave a lot of possible solutions (such as a single payer system which prevails in many modern nations, such as Canada) on the table because of emotional political arguments rather than a factual airing of the pros and cons to different solutions.

It boils down to one’s personal views.  Do you get what you pay for and if you can’t pay you don’t get it? Or should the greatest nation on earth also provide the best healthcare available to its citizens?  If so, how is it paid for?  There are no easy answers, but I think we are making it harder on ourselves than needed.  Democrats and Republicans state that they both have the same goal — to make healthcare available to our citizens and at a cost that is sustainable.  If that is the case, then everything else is politics.

To me, we have a system for providing affordable care through an insurance program called the ACA — Obamacare.  No one thinks that system is perfect.  Democrats affirm that they are willing to work with Republicans to fix what needs to be fixed.  Republicans shout that Democrats are obstructionists while jamming through a bill that even most Republicans did not get a chance to look at.

You can look it up, you don’t have to take my word for it, but in putting together Obamacare the Democrats took nearly a year, held countless hearings, folded Republican amendments into the final bill, and tried to put together a bipartisan bill.  Politics interfered at the end of that process and one could argue that Democrats jammed it through at the end.  But contrary to what you now hear, it was not a secret process and it wasn’t a slap dash final product.  I am not sure what the rush is in the Republican held Congress at this point.  This is major legislation that will impact many Americans and a large chunk of our economy. There is no need to play hurry up ball at this point.  Every piece of legislation has some perverse and unintended consequences.  Obamacare has some.  Trumpcare certainly will if it has not been properly vetted and reviewed.  It is too important to just slam through, whether or not you support the fundamental political and social theories behind it.

This process is not in the best interests of our country.  I hope that cooler heads prevail and that everyone takes a step back.  Take a deep breath.  Let’s regroup and come forward with a bipartisan approach to helping every citizen find effective and affordable healthcare.

I’m not holding my breath.

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Deal or No Deal? No Deal…. This Time. But More Will Come

“Obamacare is the law of the land. … We’re going to be living with Obamacare for the foreseeable future.”  — Speaker of the House Paul Ryan (R-WI) on 24 March 2017

The last ten days of the Donald Trump Administration has had more drama and newsworthy events than any recent presidency in memory.  Most of it was not good news.  Not good for the country and not good for the Trump Administration.  Ranging from the revelation that the FBI is conducting a long-term investigation into ties between the Trump campaign and foreign entities, to the failure of the House of Representatives to vote on a replacement for the Affordable Care Act (ACA). The American Health Care Act (AHCA) was pulled by Speaker Ryan because of its sure defeat in the House.  A defeat I may add, that came despite the fact that the Republicans had a majority in the House of Representatives, the Senate, and the White House.

There are many reasons why the bill failed, and I am sure that pundits will dissect those reasons at length as time goes by.  Among the most prominent in my view, is that as the final push began to go from theory to an actual bill, the Republicans lost sight of policy and focused primarily on politics. In so doing they ended up changing the bill in ways that left only 17% of Americans in favor of it replacing the ACA.

Despite President Trump’s promise on 17 January 2017 that his health care bill was nearly finished and would be revealed shortly, he apparently did not have one of his own and went with the proposal crafted by Speaker Ryan.  In that January interview, President Trump also insisted that his health care bill would provide “insurance for everybody” and that people “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”  Which, surprisingly from this administration, turned out not to be true.

One could also ask why after seven years of campaigning on “repeal and replace” the Republicans did not have a viable plan, worked on by all factions of their party, with the contentious issues litigated before hand, ready to go?  It became a lesson for the new majority that opposition is much easier than leadership.

Speaking of leading, President Trump learned that leading the nation and a divided government is much different, and I would add more difficult, than running Trump, Inc.  The “closer” couldn’t close and he found that threats to an equal branch of government do not carry much water when the president’s approval rating is only in the 30’s and his disapproval rating is in the high 50’s.

There are other significant issues at play and we will see how things work out in the coming months as the president moves on to more “fun” (his word) endeavors such as tax reform and infrastructure renewal.  However, I think that all concerned are naive to believe that health care is resolved for the future.  In many ways, this is just round one of a longer, continuing saga.  As always, the devil is in the details and there are many details yet to be resolved before the battle of the ACA vs. AHCA is over.

Recall that President Trump and others continually repeat that the ACA is a “disaster” and in his usual method of communicating complicated issues, tweeted that “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”  One of many such tweets where he constantly reiterates that ObamaCare (the ACA) will “explode” or “implode” depending on his mood of the day, and blaming everyone — Republicans, Democrats, bureaucrats, a long list — for the failure of the bill to pass the House.  He blames everyone but himself or his dogmatic but very inexperienced staff, even as insiders say that he never really understood the policy behind the bill, nor really had much interest in it other than as a tag line during the campaign.

“Nobody knew that health care could be so complicated.” — President Trump on 27 February 2017

Here is the real point.  In fact, President Trump and his administration can turn his prediction into a self-fulfilling prophecy.  By regulatory action, or inaction, and by refusing to defend or promote the current system, they can indeed cause it to fail.  Not tomorrow, not the next day, but over time they can ensure that it fails without the proper attention to implementing its provisions.

Nearly all impartial adjudicators, including the Congressional Budget Office, state that under current provisions, the ACA will not explode, implode, or otherwise become a disaster.  It is working. However, it is not working perfectly and could use improvement.  In particular the number of insurance companies participating are decreasing, and deductibles in some areas are increasing. There is some debate as to whether this is happening because of the uncertainty that surrounded the ACA leading into the introduction of the AHCA or other factors.  Generally, the experts say that this trend can be reversed and in any case, does not impact all Americans.

The ACA — ObamaCare if you will — can be improved and should be improved.  Just like Social Security and other programs, the original plans are rarely perfect and it is entirely reasonable to see changes that improve the process and benefits.  Hopefully, now that the histrionics from both parties are over, the real leaders of the House and Senate can sit down in a bipartisan way and work on fixing the things that need to be fixed in the ACA.  I am not optimistic that it will happen. It will be difficult because from a policy viewpoint it is expensive and from a political viewpoint the Republican majority cannot pass such legislation without significant numbers of Democrats on board.  Thus far they have shown themselves to be unbelievably reluctant to pass anything that needs Democrats to carry the day. Conversely, at this point in time, Democrats are unwilling to show support for much of anything that President Trump is pushing.  That said, I am more confident that President Trump will be willing to work with Democrats and they may in turn be willing to work with him, on the right issues.

Unfortunately, the Secretary of Human Health and Services Tom Price made a career in the House of Representatives by opposing the ACA.  Now that he is the Secretary he can make regulatory changes that lessens the coverage provided by the ACA.  He can refuse to defend in it court when challenged and he can refuse to advertise re-enrollment dates and other factors that makes it harder for people to access and benefit from the Act.  Whether this will happen or not,  time will tell, but as the president and others continue to insist that the ACA will collapse, it is entirely possible that Secretary Price will help to make matters worse.

President Trump now has the opportunity to demonstrate whether or not he is the great negotiator that he claims to be.  He can choose to show real leadership and bring the parties together and do something positive for all Americans or he can show us that his “repeal and replace” sloganeering was only that — an applause line without substance.  So far his stated intention is to “move on.”

What he cannot do is claim that he no longer has any responsibility for the future of health care in the United States, which is what he tried to do last Friday.

“I think the losers are Nancy Pelosi and Chuck Schumer because now they own Obamacare. They own it – a hundred percent own it. And this is not a Republican health care. This is not anything but a Democrat health care. And they have Obamacare for a little while longer, until it ceases to exist, which it will at some point in the near future.  And just remember. This is not our bill. This is their bill.”  — President Trump on 24 March 2017

Sorry, Mr. President.  I regret to inform you that you are the president of the entire nation and that you are responsible for the well-being of all its citizens.  And oh, by the way, it was the Republicans that could not get themselves organized to pass their own bill.

Let us all work for a better deal in the future.