The basic economics of U.S. health care makes that easier said than done. Before the ACA, the U.S. stood out from the international pack on health care in two very unpleasant ways. First, it spent a far larger share of gross domestic product on health care. Second, it was the only advanced industrial nation that left vast swaths of its population uninsured. These two doleful facts remain true, although the fraction of Americans without health insurance fell from 13.3% in 2013 to 8.8% in 2017, according to Commerce Department data.
There are several ways to get more people covered. One is to adopt a system in which the government provides or pays for universal coverage—the British or Canadian model. This won’t happen soon in the U.S., not even as Medicare for All.
A second route, advocated unsuccessfully by President Clinton in 1993, is to mandate that every employer provide health insurance to its workers. This approach might seem natural in the U.S. context because so many workers already receive health insurance that way. But the employer mandate has fatal flaws. It wouldn’t cover the nonworking population, and it would impose heavy burdens on small businesses.
For these and other reasons, many economists in the Clinton administration—including me—favored an individual mandate. But that idea was dead in the water in 1993 because it had been advocated by the Heritage Foundation starting in 1989. It was therefore a “right wing” idea.
There are problems with an individual mandate, too. For one, the high cost of U.S. health insurance means that many low- and moderate-income families cannot afford to buy policies on their own. For another, if for-profit insurance companies are made to lose money by covering people with pre-existing conditions, the government must also force young healthy people, who tend to have limited medical expenses, into the insurance pool.
Fortunately, both problems are easily solved—conceptually, that is, not politically—by mandating that everyone buy a policy and providing subsidies to the needy. Massachusetts legislators understood this in 2006. They also knew they were not writing on a blank slate; many citizens received health insurance through their jobs and didn’t want to lose it. Hence the hybrid system that became known as RomneyCare.
If this short description reminds you of the ACA, it should. The two plans are not identical twins, but there is a family resemblance. In 2010 Democrats didn’t follow in the footsteps of Romney Republicans to make them look good; they designed their plan that way because under the constraints of precedent, the underlying logic practically forces you there.
Keep that in mind: If there ever is a TrumpCare, an unlikely proposition, it’s bound to resemble RomneyCare and ObamaCare—no matter what the president claims.
Graham-Cassidy, the health bill the Senate may vote on next week, is stunningly cruel. It’s also incompetently drafted: The bill’s sponsors clearly had no idea what they were doing when they put it together. Furthermore, their efforts to sell the bill involve obvious, blatant lies.
The Affordable Care Act, which has reduced the percentage of Americans without health insurance to a record low, created a three-legged stool:
- regulations that prevent insurers from discriminating against people with pre-existing conditions,
- a requirement that individuals have adequate insurance (and thus pay into the system while healthy)
- and subsidies to make that insurance affordable. For the lowest-income families, insurance is provided directly by Medicaid.
Graham-Cassidy saws off all three legs of that stool.
- it eliminates the individual mandate.
- sharply reduces funding relative to current law, and especially penalizes states that have done a good job of reducing the number of uninsured.
- And it effectively eliminates protection for Americans with pre-existing conditions.
Did Graham-Cassidy’s sponsors know what they were doing when putting this bill together? Almost surely not, or they wouldn’t have produced something that everyone, and I mean everyone, who knows anything about health care warns would cause chaos.
Republicans are trying to ram the bill through before the Congressional Budget Office has time to analyze it — an attempt that is in itself a violation of all previous norms, and amounts to an admission that the bill can’t bear scrutiny.
.. Lindsey Graham, Bill Cassidy, and the bill’s other sponsors have responded to these critiques the old-fashioned way — with lies.
.. Cassidy has also circulated a spreadsheet that purports to show most states actually getting increased funding under his bill. But the spreadsheet doesn’t compare funding with current law, which is the relevant question.
.. That’s actually a well-known dodge, one that Republicans have been using since Newt Gingrich tried to gut Medicare in the 1990s. As everyone in Congress — even Cassidy — surely knows, such comparisons drastically understate the real size of cuts, since under current law spending is expected to rise with inflation and population growth.
.. Republicans are desperate to destroy President Barack Obama’s legacy in any way possible, no matter how many American lives they ruin in the process.
.. most Republican legislators neither know nor care about policy substance. This is especially true on health care, where they never tried to understand why Obamacare looks the way it does, or how to devise a nonvicious alternative.
.. the evasions and lies we’re seeing on this bill have been standard G.O.P. operating procedure for years. The trick of converting federal programs into block grants, then pretending that this wouldn’t mean savage cuts, was central to every one of Paul Ryan’s much-hyped budgets.
.. Graham-Cassidy isn’t an aberration; it’s more like the distilled essence of everything wrong with modern Republicans.
.. But even if the handful of Republican senators who retain some conscience block it — we’re looking at you, John McCain — the underlying sickness of the G.O.P. will remain.