At last, the seven-year-long Republican obsession with repealing Obamacare is about to come to fruition. Or not. The proposed Senate bill doesn’t exactly repeal Obamacare, but rather subjects it to a slow death of a thousand cuts. Thus, the decades-long saga of America refusing to come to terms with the medical needs of its citizens continues.
Oddly, the fans of “repeal and replace” rarely explain how their legislation will be better for the people you’d think would be the point of the exercise – patients. Instead of talking about health, they talk about economics. So, they complain that Obamacare is socialistic income redistribution, that is, higher taxes on the wealthy were used to help subsidize healthcare for the less affluent. But only an accountant would describe a doctor’s care when you’re sick as income. Helping those in need used to be called charity, not socialism. Jesus seems to have been in favor of that.
It is also argued that the goal is shifting power to the states for Medicaid, which helps fund healthcare for 73 million working poor who don’t get healthcare on the job, for their children, for 65% of elderly people in assisted living, for the disabled, for half of all births. According to Republican theory, the states are “laboratories of democracy,” and from 50 experiments will come healthcare improvements.
But in practice, quite a few governors don’t want Obamacare repealed since they can’t afford to fund Medicaid either. So, this looks more like a game of hot potato on the part of Congress. The upshot will be worse healthcare or none for people in poor or ideologically pure states. The quality of the care Americans get will depends on the luck of the draw, geographically speaking. Be careful where you’re born.
A slightly less farcical claim is that we simply can’t afford to provide healthcare for all those poor, old, underemployed, disabled, pregnant people. But this is a species of Social Darwinism. Some people, the fittest as defined by employment or net worth, deserve all the healthcare money can buy. Those who can’t afford it deserve nothing, having proven they aren’t worth investing in. Shades of Scrooge and his enthusiasm for eliminating the “surplus population.”
But even on the most gimlet-eyed green-eyeshade level, we can afford to provide healthcare for everyone. In fact, those who can’t afford insurance still end up at hospitals or emergency rooms where they cost more in critical care than if they had had preventative care all along. We just choose not to provide care rationally. Every other developed country has been able to figure out this puzzle. The Japanese, Germans, French, English, Canadians, Scandinavians and many others have some form of universal healthcare. In almost every case it costs less per capita than we are spending, and health outcomes are better than ours.
So, the objection to offering some variant on those systems isn’t that they don’t work or aren’t affordable. It’s that they require everyone to pay taxes and the government to control costs. This in anathema in America, where doctors are capitalists who earn millions and often preside over several profit centers giving them a piece of the tests or imaging they prescribe. (Doctors in Congress illustrate the point. Tom Price, the Georgia congressman turned head of HHS is worth $13 million, Sen. Rand Paul, $3 million, Rep. John Barrasso, $3 million, Rep.Phil Roe, $4 million.) Many hospitals are now for-profit monopolies. Big Pharma is big business. Payment in America is per procedure, so there’s an incentive to do a lot of tests and procedures whether the patient needs them or not.
And the original sin of American healthcare was linking insurance to employment. During World War II, employers had a hard time competing for employees since wage and price controls had been instituted, but they could offer a health insurance benefit in lieu of a higher wage and get a competitive advantage. That worked fine when most people were working for huge corporations for life, and when they all offered the same benefit, but those days are gone.
That, rather than the laziness beloved by Republican ideologues, accounts for the growing number of the uninsured who are one illness away from bankruptcy. And don’t forget that a society that relies on private insurance rather than public financing is automatically facing higher costs. Numerous studies have shown that as much as 17 cents of every healthcare dollar goes to pay for insurance overhead and profits. Aetna, Humana and the rest aren’t providing coverage for free. By contrast administrative expenses for Medicare are a trivial two percent.
In fact, rah-rah capitalist congresspersons ought to consider an alternative to fix healthcare. Since they are never going to adopt universal public health insurance, why not give every child when he’s born an account funded with a healthcare index fund. These have grown every year for the last decade and a half by 10% a year, before Obamacare and after, through recession and recovery. You can go broke needing healthcare, but not owning it.
Clearly the present system is crazy, and the proposed cure is crazier, assuming the goal is caring for the health of 320 million Americans efficiently, rationally, and economically. But that isn’t the goal. Cutting taxes on the wealthy is a goal. While ten or twenty million people will lose care under the legislation, the top two percent of taxpayers will get $272 billion in tax cuts. Reducing government expenditures is a goal. And getting reelected is a goal for people who have been promising to destroy uppity Obama’s programs. Everything else is negotiable.
But what if voters have long memories? Candidate Trump ran on the promise to replace Obamacare with something better. And he promised never to take away Medicare or Medicaid. At first, he celebrated the passage of the House bill, but someone must have told him it would not create better care than Obamacare, but less — and that it would slash spending on Medicaid. So, he called it “mean” and demanded that the Senate do better.
The Senate has done worse, cutting deeper into Medicaid. But it has timed the cuts to phase in over several years, so those running in 2018 might not have to face the backlash. But by 2020, Trump voters who took him at his word could be attending his rallies with pitchforks. Because whatever the Republicans pass will go further to making us a nation of healthcare haves and have-nots, a patchwork of states in which some provide a healthcare safety net and others where you can die on the street. Perhaps the drafters of these fixes should have remembered the Hippocratic oath: First, do no harm. And not just to your donors.