How to improve Obamacare: If Republicans were smart, they’d listen

Just think how much better the ACA could be with bipartisan fixes and buy-in. Yeah, I know; it’s a fantasy.

Imagine an alternate universe in which members of both parties work together to develop changes to the Affordable Care Act to make the law work more efficiently, cover more Americans, and cost the government less.

I know it’s ludicrous to even propose this in these embattled times, especially with Republican lawmakers’ heads stuck firmly in the sand, but ideas on how to improve the ACA are out there. Democratic lawmakers would be wise to push them publicly in easy sound bites, if for no other reason than to reinforce the notion of how stubborn Republicans are and how hard the GOP is working against the interests of the American people while Democrats are trying to help.

When he couldn’t get 50 GOP votes for the Senate version of Trumpcare, the Better Care Reconciliation Act, Senate Majority Leader Mitch McConnell had no choice but to delay action. He bemoaned the fact that—horrors—he might have to work with Democrats on health care legislation. According to a Politico story:

Failing to repeal the law would mean the GOP would lose its opportunity to do a partisan rewrite of the law that could scale back Medicaid spending, cut Obamacare’s taxes and repeal a host of industry mandates.

Instead, Republicans would be forced to enter into bipartisan negotiations with Democrats to save failing insurance markets.

McConnell delivered a similar warning Monday to Republican senators at his leadership meeting and to top GOP staffers, warning that Democrats will want to retain as much of Obamacare as possible in a bipartisan negotiation, according to Republican aides.

“If we fail, we’re going to be negotiating with [Democratic Leader] Chuck Schumer,” said one Republican staffer.

Schumer has made an offer to do just that, and so have Democrats in the House. As Schumer said in the Senate this week, according to a story on Morning Consult:

“So, I’d make my friends on the Republican side and President Trump an offer: Let’s turn over a new leaf. Let’s start over,” the New York Democrat said on the Senate floor as he called on GOP leaders to drop their push to repeal the taxes that help fund the Affordable Care Act, along with their proposed $772 billion cut to Medicaid.

Instead, Schumer said, all senators and Trump should come together for a “new bipartisan way forward on health care in front of all the American people” to discuss what the country is “really concerned about: premiums, deductibles, the costs and quality of health care.”

There may be little reason to believe the sincerity of Republican senators such as Susan Collins of Maine, who keeps floating the idea of working across the aisle to improve the ACA. Nevertheless, let’s see where such a fanciful approach might take us.

Republicans have spent seven years screaming the mantra of “REPEAL AND REPLACE” even though they had no legislation waiting in the wings. Both the House and Senate versions of Obamacare replacement are so toxic that the bills’ approval ratings hover between 12 percent and 17 percent. They’re so bad that they’ve pushed ACA approval into positive territory, and support for Trumpcare has dropped even among Republicans. Polls commissioned by the American Medical Association, hardly a bastion of liberalism, show that key aspects of both bills are deeply unpopular in seven battleground states. Medicaid now has widespread support, and a majority want Medicaid funding increased or at least maintained, not drastically cut, as both Trumpcare bills would do.

It’s obvious why both pieces of legislation are so unpopular—the bills are crap. They’re tax-cut bills masquerading as health care bills. They would take us back to the bad old days of lifetime benefit caps and the ability to deny coverage for preexisting conditions. They would raise premiums. They would take 22 million to 24 million people off the insurance rolls within 10 years and would gut Medicaid.

Polling by Morning Consult shows that the country wants a bipartisan solution.

Morning Consult surveys from the past few months show a strong appetite for bipartisan reform to former President Barack Obama’s 2010 health care law, with an increasing share of Republican voters embracing that view. A mid-June survey found that 65 percent of registered voters prefer that Republicans in Congress compromise with Democrats to reach bipartisan reforms on health care, while just 18 percent said Senate and House Republicans should handle the overhaul on their own.

And working with Democrats to upgrade and enhance the Affordable Care Act could be Republicans’ salvation. Working in a bipartisan manner would have the benefit of improving the current law while giving them political cover. According to a story from New York Magazine:

Obviously, a bipartisan bill would have very different parameters. Democrats are not going to support a huge tax cut for the affluent or a plan to cut insurance subsidies by a trillion dollars. On the other hand, the thing Democrats would happily do also happens to offer enormous political benefits for the majority party.

If Donald Trump’s candidacy has made nothing else clear, it’s that Republican voters have little attachment to right-wing economic doctrine. They hate “Obamacare,” but they favor many of its specific elements, especially Medicaid. What they want is a bigger plan, not a smaller one. Republicans have denounced high premiums and deductibles, and Trump ran promising to make sure everybody had better coverage than they get under Obamacare.

A dozen or so Republican senators who are potential “no” votes have been trooping in and out of Mitch McConnell’s office as the majority leader is desperate to promise them something—anything—to get to 50 votes. But the constant barrage of bad news about Trumpcare polling and the even worse optics of arresting disabled protestors is taking a toll. After the Fourth of July weekend, when constituents across the country won’t be shy about loudly criticizing the proposed inhumane cuts to their elected officials, what’s McConnell going to do then? Wait for Donald Trump’s “big surprise”? Despite Vice President Mike Pence’s optimism about passing a bill by the end of the summer, others say the divide among Republican senators is too great for anything to pass.

So assuming that Republicans are forced to hold their noses and talk to Chuck Schumer, as McConnell seems loath to do, why should Democrats cooperate with them? Here’s the reason, again from New York Magazine:

From a pure political standpoint, the Democrats have a win-win choice. They’ll gain if Trumpcare fails in Congress, and they’ll gain even more if it is signed into law. The only way they won’t score political points off the issue is if they join with Republicans to patch up the system. And yet many and perhaps most Democrats are probably willing to make this sacrifice for the same reason they took the risk of voting for Obamacare in the first place: They care a lot about health-care policy outcomes, and are willing to sacrifice seats to pursue them.

Sen. Collins and Sen. Bill Cassidy of Louisiana are two Republicans who have taken baby steps in talking to Democrats about changes to the ACA. Another Politico story described the beginnings of those efforts back in May. But once the House tweaked its way into passing the American Health Care Act, making an already bad bill worse, the bipartisan talk cooled, even though several senators from both parties still say it would be a more successful route to take.

Though Republicans guarantee there will be a partisan repeal vote at some point this year, some senators and aides believe the chances of failure are greater than success. Crafting a Plan B, they say, is wise.

“The stakes are high, and the possibility for failure is high,” one Republican senator said of the partisan repeal effort. The senator said it would not be surprising if Republicans are ultimately forced to seek a deal with Democrats. …

Collins said much the same in a recent interview.

“I really want us to have a bipartisan bill. I just think will be so much better. And we have better ideas,” she said. “So that’s my goal. You end up with a better bill, you end up with better acceptance by the public.”

There’s no shortage of ideas on how to improve the ACA. Let’s look at a few possible areas of change. Here are some often-recommended ones, coming from sources as varied as the New Yorker and The Wall Street Journal.

  • Payment system changes. The existing fee-for-service system rewards the wrong behavior, making care less, rather than more efficient. There are other approaches, such as bundled payments and accountable care organizations.
  • Public reporting of quality performance data. Scoring systems for hospitals and physicians would give patients real data to choose providers.
  • Increased and fairer subsidies. Subsidize insurers to enter unattractive markets. Raise the level of subsidies for plans bought on the exchanges or raise the income thresholds at which the subsidies phase out.
  • Pricing transparency. Consumers need information to make the best choices about their care.
  • A simplified ACA bureaucracy. The new structures in the ACA may have been written into the law for the right reasons, but they have forced medical practices and hospitals to hire more staff to meet the new regulations, not to deliver care. That forces costs up, without helping patients.
  • A public option for insurance. Well, DUH.

Ideas on reforming the ACA are all over the political and economic spectrum:

Let’s look at two proposals from two very different sources: Paul Krugman of The New York Times and the AMA. You’ll find that there’s overlap, with obvious differences. First, Krugman:

One important answer would be to spend a bit more money. Obamacare has turned out to be remarkably cheap; the Congressional Budget Office now projects its cost to be about a third lower than it originally expected, around 0.7 percent of G.D.P. In fact, it’s probably too cheap. A report from the nonpartisan Urban Institute argues that the A.C.A. is “essentially underfunded,” and would work much better — in particular, it could offer policies with much lower deductibles — if it provided somewhat more generous subsidies. The report’s recommendations would cost around 0.2 percent of G.D.P.; or to put it another way, would be around half as expensive as the tax cuts for the wealthy Republicans just tried and failed to ram through as part of Trumpcare.

What about the problem of inadequate insurance industry competition? Better subsidies would help enrollments, which in turn would probably bring in more insurers. But just in case, why not revive the idea of a public option — insurance sold directly by the government, for those who choose it? At the very least, there ought to be public plans available in areas no private insurer wants to serve.

There are other more technical things we should do too, like extending reinsurance: compensation for insurers whose risk pool turned out worse than expected. Some analysts also argue that there would be big gains from moving “off-exchange” plans onto the government-administered marketplaces.

Here’s a health reform laundry list from the AMA, which strongly disagrees with both the House and Senate versions of Trumpcare:

  • Ensure that individuals currently covered do not become uninsured and take steps toward coverage and access for all Americans.
  • Maintain key insurance market reforms, such as preexisting conditions, guaranteed issue and parental coverage for young adults.
  • Stabilize and strengthen the individual insurance market.
  • Ensure that low/moderate income patients are able to secure affordable and adequate coverage.
  • Ensure that Medicaid, CHIP and other safety net programs are adequately funded.
  • Reduce regulatory burdens that detract from patient care and increase costs.
  • Provide greater cost transparency throughout the health care system.
  • Incorporate common sense medical liability reforms.
  • Continue the advancement of delivery reforms and new physician-led payment models to achieve better outcomes, higher quality and lower spending trends.

So why won’t Republicans do the smart thing and work with Democrats? For Donald Trump, it’s all about “winning” and sticking it to his predecessor. For McConnell, it’s purity of party over what’s good for the country. And there are no bigger ideologues than tribal Republican voters. But when polls show that even they are starting to abandon Trumpcare, maybe it’s time for McConnell to bite the bullet and take another look.

Remember Democrats’ response when the first attempt to pass Trumpcare in the House failed? They said they were willing to help fix the Affordable Care Act, for the sake of the American people. Remember this tweet from Democratic Rep. Sean Maloney of New York?

Medicare first passed in 1965 and has undergone changes throughout its 50-year history. The first expansion came under President Richard Nixon in 1972, and it has been tweaked when necessary ever since. Assuming (and I know it’s a lot to assume) that some version of the ACA survives this partisan onslaught, any changes made to President Obama’s signature achievement will only make it stronger.

At the end of The Princess Bride, after Inigo Montoya finally dispatches the six-fingered man who killed his father, he says, “You know, I’ve been in the revenge business so long, I don’t know what to do with myself.”

That’s the fix Republicans are in right now. They’ve run so long and so hard against Obamacare without any ideas of how to replace it that they don’t know what to do now that they’re in power with nothing to offer but ideas that the American people find repulsive.

Maybe McConnell and co. should take the suggestion from Westley: “Have you ever considered piracy? You’d make an excellent Dread Pirate Roberts.” Of course, some would suggest that Republicans act like pirates already. I wonder if Mitch McConnell has a boat…

Originally posted on Daily Kos on July 2, 2017.

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