Replacing Obamacare: The Strategies and Options
This is the fourth and final article in a series on the rollout of Obamacare, and how the law will change our health care system. Each of the past two weeks, we have published two articles: one on the changes in medicine and medical care and one on changes in the insurance industry. We hope this series of articles will help you make better decisions when it comes to your health care and how you buy insurance.
The Republicans in the Senate and House are now involved in the early stages of what appears to be a major internal food fight over how to leverage the GOP’s opposition to Obamacare with the need to pass a continuing resolution to keep government financed and, soon thereafter, to raise the nation’s debt ceiling. Some conservatives in Congress, encouraged by a few talk radio personalities, are supporting a strategy of seeking to defund Obamacare as their price for allowing the government to continue its business in other areas and to continue to borrow. For fiscal 2013, the federal deficit will be about $800 billion, a reduction from the trillion-dollar plus deficits of the prior Obama years due to additional tax revenues from the year-end 2012 deal on the “Bush tax cuts,” Obamacare tax increases, and some modest spending cuts due to the sequester.
Other Republicans wish to delay the implementation of Obamacare until 2014, focusing in particular on the individual mandate. Since the administration unilaterally delayed for a year the employer mandate (without asking Congress to bless this action), some Republicans seek to formally authorize the delay for both the employer and individual mandates.
Republicans in the House have passed an Obamacare repeal measure over three dozen times since they won control of the House in the 2010 midterm elections. Naturally, this effort never went anywhere in the Democratic-controlled Senate. Even if some Republican Senate candidates had not self-destructed in 2010 and 2012 in winnable races and the GOP had won control of that body, an Obamacare repeal measure that went to the president would have been vetoed.
The president is reeling from a perception that he has been a weak leader and badly mishandled the Syrian chemical weapons “red line” he had set, even if most Americans are happy that we are not engaged in a new military effort. Also, the economy is still struggling, and Obamacare is increasingly unpopular with the opening of the state exchanges now less than a week away.
A constant refrain from left-of-center supporters of the new health care law has been that the Republicans want to get rid of Obamacare, but have never offered anything substantive to replace it. Whereas Obamacare, at over 2,000 pages and with well over 10,000 pages of supporting regulatory language so far, is presumably just what the doctor ordered.
However, the Republicans have in fact offered substantive proposals, and this week House Republicans again offered a health care bill to replace Obamacare. Of course, it does not address every aspect of the legislation the Democrats rammed through in 2010, and should not be viewed as a provision-for-provision substitute.
The Affordable Care Act expanded Medicaid coverage up to 138% of the poverty level for individuals and families. Justice Roberts’ decision affirming the legality of the individual mandate also allowed states to decline to expand Medicaid without risk to their current level of federal funding for the existing Medicaid program. The other major access expansion came through employer and individual mandates. In each case, penalties would be assessed for employers of a certain size not providing health insurance to their full-time employees, and for individuals who did not purchase an individual insurance policy in the new exchanges. Given the “free shot” to enact a health care reform bill relying solely on Democrat votes, the Obamacare bill was also larded with thousands of pages and hundred of provisions regulating just about every aspect of the industry and the delivery system.
The new GOP alternative is a different animal entirely from Obamacare. It is designed to support free market competition rather than regulate private market activities. One way it does this is by allowing cross-state competition in the private insurance market. Obamacare limits the type of insurance plans that can be provided in the state exchanges in terms of the percentages of plan cost that must be provided in coverage benefits, and mandates that all coverage in every state include a fairly comprehensive package of health care services in all plans offered on exchanges. True insurance competition in individual states would allow much greater variability in plan offerings. It has been demonstrated for many years that when individuals or employees have “skin in the game" -- meaning their own dollars are at risk -- they are more cautious about health care spending. They also respond to financial incentives for promoting better health (smoking cessation, exercise, weight management). High-deductible, catastrophic policies are attractive to many younger people and to those in good general health.
The House GOP plan expands the use of health savings accounts, which enable individuals to save money (as in an IRA or 401K) or to use it on health care services they choose -- e.g., dental care, cosmetic surgery, LASIK surgery, eyeglasses. Obamacare placed limits on these programs as well as on flexible spending accounts that many companies had set up. The designers of Obamacare seemed to not like individuals making their own choices.
Obamacare is equivalent to a prepaid health care insurance benefit: comprehensive coverage, high cost, minimal risk for the individual. The supporters of Obamacare point to the subsidies and argue that the cost of many polices on the exchanges will be quite low. But the subsidies are paid for by the federal government -- they are not a free good. The net cost of the insurance after the subsidy to the insured does not represent the full cost of the policy, nor indicate any cost savings to the system. The subsidy is, pure and simple, a new welfare program. The government chips in to make health insurance cheaper for certain people while other people foot the tab through higher taxes. Several Obamacare supporters have been honest: this is redistribution at work, not a health policy reform bill.
Other Obamacare supporters, like Ezra Klein and Jonathan Cohn, have argued that the new exchanges will bring down the cost of health insurance for individuals. For those who could not buy insurance or had very high cost options due to medical histories, this is true. These authors argue more broadly, however, pointing to some states where the net cost to the individual on an exchange will not be very high. It is a false comparison to argue that this represents any kind of cost savings compared to the cost for individual policies before Obamacare. A true comparison would be the cost of insurance on an exchange without any subsidy versus a similar benefit package offered in a state before Obamacare.
The new House GOP plan also addresses the over-utilization problem by addressing malpractice, which is a major contributor to the practice of defensive medicine and a major source of higher volume generated by physician-ordering patterns. The cost of malpractice insurance in states which have instituted tort reform versus those which have not is striking. Trial lawyers are a major source of funding for Democrats in Congress, and Democrats have always avoided taking them on regardless of the national interest.
One criticism of the GOP plan is that it does not address those who have been denied coverage in the past in a systematic fashion, so that they are guaranteed coverage in the future (“guaranteed issue”). This criticism is false: the GOP plan does support expansion of state pools that have been established to deal specifically with this group.
Having had experience with one already-operating state pool designed for those with pre-existing conditions who had difficulty obtaining coverage, I can attest that the program works well and has significantly limited annual premium increases. Representative Steve Scalise of Louisiana described the approach:
"We work with the existing state high-risk pools that are out there,” Scalise said in regards to people with pre-existing conditions. The bill provides $25 billion over 10 years to enhance the state pools, “so an individual with pre-existing conditions can go and buy at market rates."
In essence, America had a real problem -- those who were locked out of insurance (a group numbering no more than a few million). But rather than address that specific problem, Obamacare instead tried to create a systemic change, provide subsidies or Medicaid to thirty million people without coverage, and to set new rules for everybody else.
The left has always wanted universal coverage with a single payer -- the federal government. Obamacare was a plan to move the country along the continuum towards that goal by having the federal government pay all or much of the cost of insurance for tens of millions of people.
Cynics have argued that the real goal was to create such chaos, that the simplicity of single payer would be appealing in the future to replace the patchwork of different federal programs and employer-sponsored insurance. The more one looks at what Obamacare delivers, now that some people have read the bill, the easier it is to become a cynic.
Other articles by Rich Baehr in this series: