It is far easier to convince people of the advantages of gaining benefits they don’t understand than to sell them on the advantages of avoiding costs that they do understand. That seems to be the lesson to be learned by anyone wondering what’s next for health care reform after the House Republicans’ bungled attempt to repeal and replace the Affordable Care Act.
Along with the rising insurance premiums under the ACA, that program’s infamously inept rollout and the problems people encountered with keeping familiar providers made “Repeal Obamacare!” a popular slogan for electioneering. Just citing the problems implied a solution. Some unspecified something had to be better than this.
But when the thrill of victory turned into the grind of governance, the airily implied solutions turned into complicated costs to be avoided – the premium-raising costs of covering “essential health benefits,” the personal freedom-limiting costs of mandating the universal purchase of health insurance, the tax-raising costs of subsidizing premiums for households below specified income levels, and, least transparently and most cynically of all, the tax savings from reduced health spending that would make the Republican “second front” of tax reform easier to finance and sell.
In the end, all these theoretical avoided cost arguments, all of these “trust me, the replacement will be better” assurances, paled to insignificance compared to the harsh reality of real constituents losing access to health care and identifying very clearly the people who took it away.
The ideological rigidity and political ineptitude of the past week (as well as the months of poor thinking that led to this inevitable outcome) now present all those interested in improving health care policy with a new opportunity. Courageous Democrats can reach out to their now-sobered Republican colleagues who sensibly defied both their leader and their president and offer to work together to improve the system in place.
But the first order of any such collaboration must be to establish a first principle of expanding rather than restricting access to health care. The primary reason for failure of the repeal effort was not affection for the current system, but fear that its insanely complicated, internally contradictory, riddled-with-cross-subsidies and totally opaque operations would be forced to exclude more regular, everyday people.
The only way that bipartisan efforts to reform (and perhaps rename) Obamacare is to address this fear head on, to say that yes, cost containment is important, yes, competition is good and, yes, finding ways to return the patient-provider relationship to the center of health care delivery is important, but bottom line, you will get care, you will be treated – and not just at the last minute in an emergency room.
Addressing this fear of loss of access will be expensive. But arguing about what constitutes a minimum acceptable level of assured health care service and what such services are likely to cost would be a vast improvement over hiding the total cost by cobbling together a mélange of taxes imposed on entities deemed “rich” or somehow engaged in the health care industry (like medical device manufacturers).
Such backdoor ways of paying the bill both hide the true total cost behind a maze of financial trickles and create all manner of dysfunctional incentives. If we are ever to have an effective health care system, it must have a clear, comprehensive and transparent cost. And everyone should know it. Only in this way will it be possible to understand what drives that cost and, thus, how to make changes to reduce them – something an improved Obamacare should seek to do.
Much of the now-failed Republican plan was based on exclusion: Don’t mandate insurance, don’t mandate specified coverages and limit entitlement access. A House committee recently voted to advance a separate Republican-backed bill that allows employers to impose hefty financial penalties on workers who decline to get genetic tests as part of workplace wellness programs. Such an approach necessarily generates fear. Rather than allowing access to health care to define us a community, as a nation, it further set us apart.
The alternative approach that now seems more likely to arise will face a far higher probability of success if it begins with broad inclusion and then, on a secure and fearless foundation, sets forth firmly on the path of instilling and rewarding more individual responsibility for health decisions on the part of the consumer while experimenting with innovative ways of providing services more efficiently on the part of the providers.
Consulting economist Charles Lawton, Ph.D., can be contacted at cttlaw3@gmail.com.
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