Paul Ryan and the House leadership don’t seem to understand what they’re up against as they seek to rebuild the health insurance market.
When the Congressional Budget Office published its score of the Republican Obamacare replacement bill, the American Health Care Act, something that should have already been obvious to the GOP leadership became even more painfully so.
And yet House Speaker Paul Ryan and his team for some reason didn’t take the opportunity to articulate it.
What was obvious from the lede of every mainstream media story on the CBO’s scoring, namely that the bill would “drop” some 24 million Americans off their health insurance, including 14 million in its first year, was that the CBO’s score was a guilty verdict on Obamacare — not Ryan’s bill.
“We’re saying the government’s not going to force people to buy something that they don’t want to buy,” he said.
“And if we end an ObamaCare mandate that says you must buy this government one-size-fits-all plan, guess what? People aren’t going to buy that.”
Ryan said “of course” the CBO is suggesting that if the government isn’t going to “make people do something they don’t want to do, they’re not going to buy it.”
All true as it goes, but that’s not quite the indictment of Obamacare it needs to be. Ryan needed — still needs — to say that the CBO just admitted some 14 million Americans are being forced to buy crappy, overpriced health insurance because of a tyrannical, un-American nanny state overreach which is unsustainable in a free society, and the CBO’s score proves the moral imperative of reversing that overreach and insuring that government never attempts it again.
Ryan is simply too much of a policy wonk to make such a statement, and that’s one reason why he seems to have so much trouble connecting to a Republican base that is animated a whole lot more by principle than wonkery.
Ryan and his team did make good points about the CBO scoring — namely, that this bill would bring deficit reduction compared to Obamacare, that it bends down the cost of insurance premiums and that the bill almost surely brings competition back into a market in which a third of the counties in America operate under a health insurance monopoly. And despite a lot of the caterwauling about the bill on both sides of the aisle, it probably does deliver significant improvement to one-sixth of the American economy. Avik Roy’s piece at Forbes on the bill and its CBO score is well worth a read as a primer on the policy effects of Ryancare, and readers of it might well conclude the bill is supportable.
As a piece of policy, that is.
But let’s be honest here. As a political exercise, this whole program is a mistake.
Frankly, the GOP leadership needs to pay heed to what Donald Trump has been telling them. Trump has said time and time again the best political move Republicans in Congress can make is nothing. Obamacare is collapsing; let it collapse and, once it does, it will take the Democrat party down with it.
As it stands, the only real success Obamacare has had has been to put more Americans on Medicaid by expanding that program to cover working-class people who used to have health insurance through the private sector until stupid government regulations drove the cost beyond their means. As Roy notes, the CBO scoring of Ryancare assumes five million people will go off Medicaid and become uninsured if the bill should replace Obamacare.
Think about that for a minute. Medicaid is free. Why would five million people choose to drop free health insurance if the individual mandate in Obamacare were to be repealed? There is but one answer — Medicaid sucks, and it lacks value to those who have it.
Which is true. Most doctors won’t take Medicaid because the paperwork for reimbursement is high and the reimbursement amounts are low. Medicaid is therefore the illusion of health insurance, which is why multiple studies of healthcare outcomes have shown there is negligible difference between people on Medicaid and people who are uninsured.
And signing millions of people up for illusory health insurance is the Democrat party’s grand achievement justifying their destruction of the private health insurance market.
The AHCA is supposed to be the first act of a three-act play, followed by a host of regulatory changes DHHS Secretary Tom Price will make and a second bill containing those policy reforms that supposedly can’t be passed through the budget reconciliation process. Sen. Tom Cotton (R-Arkansas), appearing Monday on the Hugh Hewitt radio show, put paid to this strategy…
Hugh, there is no three-phase process. There is no three-step plan. That is just political talk. It’s just politicians engaging in spin. This is why. Step one is a bill that can pass with 51 votes in the Senate. That’s what we’re working on right now. Step two, as yet unwritten regulations by Tom Price, which is going to be subject to court challenge, and therefore, perhaps the whims of the most liberal judge in America. But step three, some mythical legislation in the future that is going to garner Democratic support and help us get over 60 votes in the Senate. If we had those Democratic votes, we wouldn’t need three steps. We would just be doing that right now on this legislation altogether. That’s why it’s so important that we get this legislation right, because there is no step three. And step two is not completely under our control.
I honestly believe Ryan et al. mean well with this bill, a belief I have no doubt most of our readers don’t share. It doesn’t matter. We already know that the Democrats have learned to weaponize their failure to govern, and by trying to fix the damage they’ve done with Obamacare Ryan and the GOP majority will merely take ownership of the failure. They’re trying to defuse the bomb, and they’ll be blown up in the attempt.
Take Trump’s advice and let it burn. Drag the Democrats into the conflagration and let them be roasted.
But not the public. Let the public escape. Let the market save the health insurance industry. It isn’t all that hard; it simply requires a willingness to do what it takes to win.
Deem whatever you want to fit within the budget process, and do four things.
Pair an interstate health insurance market with a nominal half-cent “standardization fee” or some such trifle (which you can repeal next year), and call that sufficient to pass insurance across state lines through reconciliation.
Equalize the tax treatment of individual and employer-based health insurance, which would make insurance portable and eliminate a host of problems in the market; that’s tax policy, so it fits in the budget process.
Create an opening to restore health savings accounts to the market, allow every financial institution in America to offer them as a financial product, and allow parents a tax credit to build HSA’s for their children; the long-term effects of doing so are to create an entire generation of Americans who think completely differently about health insurance, and in the short term that makes the whole policy passable through reconciliation.
And create a larger opening for people to buy group insurance outside of employment, otherwise known as association health coverage; the difference in price between individual and group insurance would save untold millions of Americans lots of money and spin off lots of other benefits. How to shoehorn that into the reconciliation process? Who knows? Who cares?
Doing those four things would create cracks in Obamacare the market could seep through and save the entire health care sector when the status quo crumbles to dust in a year or two. None represent a comprehensive health care reform, which is a good thing — comprehensive reform of anything at the federal level is a dubious possibility in the best of circumstances, and it certainly isn’t possible when the media and the Democrats are invested in sniping from the trees rather than helping to fix what they destroyed.
Luckily, it isn’t needed. Government can’t fix the insurance market; all government can do is destroy it. It so happens that’s what the Democrats are counting on. Obamacare was designed to collapse into single-payer socialized medicine, so they’re going to do everything they can to resist efforts to alter the current trajectory.
Don’t fall into that trap. Just ram through the four reforms mentioned above and let them germinate. In a year or two, an Obamacare repeal won’t even be the Holy Grail; even the Democrats will agree it’s an obsolete failure.