Decades from now, the collapse of Republicans’ campaign to repeal the Affordable Care Act (ACA) may be seen as the moment America finalized its commitment to healthcare for all.
Democrats shouldn’t risk this historic victory by rubbing it in. Some want to seize this moment to press for single-payer. Others secretly hope Republican stubbornness will stymie tweaks to ObamaCare’s individual markets, sowing chaos they can blame on the GOP.
President Trump’s threats to “implode” these markets by ending the ACA’s subsidies to insurers for low-income subscribers offer temptation along these lines. But by resisting it, Congressional Democrats can lock in the ACA’s main achievement — making coverage for all the starting premise for political contests over healthcare.
The sudden bloom of health policy bipartisanship in the House and Senate offers a singular opportunity. With Majority Leader Mitch McConnell’s tacit agreement, Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the Senate Health Committee’s chair and ranking minority member, are crafting legislation that would keep Trump from cutting off the ACA’s insurer subsidies, which pay for reduced medical cost-sharing for low-income insureds. The deal in play would secure these subsidies in exchange for state “flexibility” to let health plans exclude services that the ACA requires.
For health policy progressives, “flexibility” is a foul word — code for carte blanche to cut services they see as vital. They ought to get over this. States can be given room to relax mandates so long as insurers cover the preventive, therapeutic, and supportive services widely understood to constitute decent medical care.
Heaven and hell, of course, lurk in the details, but here are some simple markers:
- Bare-bones health plans that appeal selectively to people unlikely to need pricey care should be off-limits because they wreak havoc on the cost-spreading needed to make insurance markets work;
- All evidence-based, cost-effective care should be covered; and
- States should be free to permit plans to exclude services that pursue culturally-contested purposes, beyond the traditional therapeutic realm.
I wince at the thought of allowing insurers to exclude, say, gender reassignment or confirmation surgery (even the name is contested) or late-term abortion. But what’s mandated in Massachusetts needn’t be the same in Mississippi; a dose of cultural federalism could help to firm up our fractious country’s commitment to decent healthcare for all.
So could incorporation of free-market conservatives’ health-policy favorite — expanded medical savings accounts (MSAs). The progressive rap against MSAs is their reverse-Robin-Hood regressivity — their tax-exempt status delivers greater benefits to Americans in higher tax brackets. But the easy fix for this is to fund lower-income Americans’ MSAs via tax credits. One could go further, by allowing people to purchase insurance on the individual market using pre-tax, MSA dollars — and even by creating MSAs as a default for all taxpayers, with freedom to opt out.
Supporters of single-payer, meanwhile, ought to press now for the so-called “public option” — the opportunity to buy into Medicare (or a similarly-structured public plan) via the insurance exchanges. Once a core feature of the Obama campaign proposal that became the ACA, the public option was bargained away to bring powerful healthcare industry stakeholders on board.
An affordable public plan would both heighten competition on the exchanges and safeguard Americans against private insurers’ departure from them. Its pro-competitive, cost-containing power would be maximized were it available nationally, but the public option could be part of a bipartisan suite of state flexibilities.
Healthcare providers and insurers will surely resist, fearing the public plan’s purchasing power and pricing clout. Its prospects for inclusion in a package of ACA bug fixes and tweaks this fall are poor. But putting it on the table now would restore it to the public agenda as the next election cycle looms, positioning Democrats as proponents of a pragmatic, longer-term insurance-market fix.
Such a fix will be necessary to secure America’s new commitment to decent healthcare for all. So will continued resistance to efforts to weaken Medicaid as a vehicle for access to mainstream care. Health-policy progressives should treat this summer’s stunning victory as an opportunity to lock in this national commitment long term, by shoring up the ACA’s market-centered design rather than overplaying their hand.