From the very beginning, I have argued that ObamaCare was ultimately designed to fail. Its basic contradiction is that it was founded on a fundamental hostility toward the entire idea of health insurance, which Obama and the Democrats view as inherently parasitical. Yet the Affordable Care Act is a scheme to require mandatory, universal purchase of the very product they despise.How do you square that circle? Simple. ObamaCare mandated and subsidized the purchase of health insurance, but on terms that obviously made it unfeasible over the long term. Obama did so on the presumption that Democrats would be able to come back later and blame the fiasco on those greedy private insurers, then go for what they really wanted all along: a “public option” modeled on Medicare, as a further stepping stone toward “single payer,” i.e., socialized medicine.
Could such a plan win approval by Congress? Ummm, maybe. Two factors weigh in its favor: first, the fact that after selling Obamacare as a program for middle-class families who were anxious about losing their coverage if something went wrong, Democrats delivered a plan that made a lot of middle-class families worse off, and few of them better off.Most of the benefits have flowed to people making less than 250% of the poverty line, while most of the costs — in the form of taxes, more expensive and less generous insurance plans, and reduced consumer choice — were borne by folks above that level, including folks who aren’t really all that far above that level. Those people are angry, and they’re more likely to vote than the program’s beneficiaries.
The second thing that might make such a plan politically viable is the continuing problems in the insurance exchanges. Until prices stabilize, we remain at risk of seeing the number of uninsured start to march back upward, as unsubsidized consumers start to drop their high-priced, high-deductible, narrow-network insurance. Those drops will be concentrated in people who don’t qualify for subsidies, and as mentioned in the paragraph above, those folks are more likely to vote than the beneficiaries.
Trump appears to be borrowing some of the language behind a traditional conservative Republican health reform proposal, which involves facilitating competition in health coverage through the sale and purchase of insurance products across states. It’s sometimes referred to as interstate competition or competitive federalism, or even just “consumer choice.” The origins of this proposal have a history of almost 15 years. Some business groups in the small-group market started floating the outlines of this idea in 2001. I wrote the first draft in policy terms at a Cato conference in July 2001, and subsequently published the academic-style version in the Cato Journal the following year. Then-Rep. Ernie Fletcher (R-KY) proposed the first legislative bill on this front in 2002. Subsequent tweaks to those concepts on Capitol Hill were championed by then-Rep. John Shadegg (R-AZ), and, in later years, by Rep. Tom Price (R-GA) and Rep. Marsha Blackburn (R-TN). Presidential candidate Ted Cruz introduced a bill similar to Blackburn’s in the U.S. Senate.
Earlier this month, Speaker Paul Ryan announced six task forces, each comprised of House Committee Chairmen, to develop a “bold, pro-growth agenda.” What was remarkable was that one of the task forces was on health care reform. Many had thought Congressional Republicans were investing too much time and energy grandstanding Obamacare repeal, and not enough developing a credible alternative.
That may have changed with the selection of four Committee Chairman to the Health Care Reform Task Force. They are: Budget Committee Chairman Tom Price (R-GA), Education & the Workforce Committee Chairman John Kline (R-MN), Energy & Commerce Committee Chairman Fred Upton (R-MI), and Ways & Means Committee Chairman Kevin Brady (R-TX).
The White House’s defeat on that, as well as several other Obamacare taxes, comes as a series of problems have piled up since coverage expansion kicked in two years ago, from collapsing co-op health plans to double-digit premium increases. No single one of them is likely to prove fatal, but together they have significantly weakened the law that Obama spent much of his presidency fighting for.
By joining with Republicans to delay the Cadillac tax, in particular, the president’s party chose the short-term demands of organized labor — a key ground-game player going into an election year — over the long-term goals of Obamacare. They offered fresh ammunition to Republicans who say the law is a money pit. And they showed a lack of political will to make Americans change their habits on health care spending.
“Is it the death knell? No. But it is harmful,” said Peter Orszag, Obama’s OMB director during the drafting of the law.
The Affordable Care Act also grants substantial flexibility in its implementation, a feature Mr. Obama has repeatedly exploited. The new president could suspend penalties for individuals and employers, enforce income-verification requirements, ease the premium shock on young enrollees by adjusting the community rating system, allow different pricing structures inside the exchanges and alter provider compensation. These actions could begin dismantling the most pernicious parts of ObamaCare and prevent its roots from deepening as Congress debates its repeal and replacement.
So let’s recap. Obamacare has depressed job growth, costs are escalating at a higher rate, barely a dent has been made in the numbers of uninsured, and insurers are either exiting the markets or failing altogether. Under any other circumstances, a program that failed on its promises so badly would have all sides moving quickly to repeal it and work on a replacement. Don’t bet on that outcome from this White House and its dwindling number of Democratic supporters on Capitol Hill. They will surely try to sell us the illusion of competence and success.
That doesn’t mean we have to buy it.