Groups such as Indivisible and People’s Action deserve a lot of credit for the Republican failure to repeal the Affordable Care Act. The loud pushback from citizens at lawmakers’ town halls and elsewhere demonstrated that taking away millions of people’s health care insurance could be political suicide.
The upside to all the political drama was months of discussion over what kind of health care Americans really need. Our appetites have been whetted. We now face a historic opportunity to move forward on the goal of universal health care coverage.
Three possibilities are becoming politically ripe for action.
The drums are beating loudly in progressive circles for a single-payer system, such as “Medicare for All.” Others, such as Paul Krugman and Michael Tomasky in their columns in the New York Times, caution that “Medicare for All” is a bet we’re unlikely to win at this time. Under a “Medicare for All” plan, the government, rather than insurance companies, pays medical bills with our tax money. Krugman and Tomasky explain that Americans do not like their taxes raised, that many are happy with their employer-provided insurance, and that when you get the entire health care industry lined up against you (the insurance industry, Big Pharma, the American Medical Association, and others) you’re likely to get clobbered.
So what are the opportunities, given the political polarization of our time?
A first step is damage control. The Democrats, together with the more open-minded Republicans, must shore up federal subsidies to prevent the insurance markets from collapsing or premiums rising to levels unaffordable by millions.
After that, three possibilities are becoming politically ripe for action.
Drug price control
Americans in both parties are angry about high drug prices. Kaiser Foundation polls show across-the-board support for lowering the cost of prescription drugs. Martin Shkreli was dubbed by media “the most hated man in America” when, as head of Turing pharmaceuticals, he jacked up the price of the anti-parasitic drug Daraprim, from $13.50 to $750. Mylan evoked outrage by increasing the price of the EpiPen by 400 percent. The pharmaceutical companies, of course, will try to crush any effort to control prices and undermine their profits. They succeeded in defeating California’s 2016 drug price control ballot initiative. Next, Ohio will try in November. But insurance companies have reason to like such controls. Some doctors and hospitals may like it. And millions of consumers will like it a lot.
The public option
We now have insurance exchange markets where insurance companies are reluctant to do business. That provides the context to offer the option of the government offering the insurance – essentially allowing people to buy into Medicare. Insurance companies might fight it – rightly seeing it as a slippery slope to a system with a single payer. But lawmakers facing constituencies (often in predominantly rural, red states) with no good choices to offer them may find this a move they could back.
Lower the age for Medicare
Politically, such a move would have built-in fans – those who become newly eligible or close to it. But how about all those industry players that would crush a “Medicare for All” platform? While “Medicare for All” eliminates the main function of insurance companies, lowering the age by just a bit, to 55 or 60, may not create such a big backlash. The reason is that older people are more expensive to insure than younger people. So getting the 55-64 age group out of the insurance pool has advantages to insurance companies, especially with ACA rules that say they can’t charge older people more than three times the amount charged to younger people.
These are three modest reforms. Why settle for these when what many want is “Medicare for All”? Physician and author Atul Gawande provides a useful historical analysis.
Just before the development of the Affordable Care Act, The New Yorker published Gawande’s insightful article “Getting There from Here.” In it he points out that other countries got to universal health care coverage not by some bold overhaul of their existing system, but by building on what they had.
For Great Britain, that meant a fully socialized system. Because of the massive expansion of government health care during World War II, by 1948, when they instituted national health care, a government run system was already in place. The shift was hardly even noticed. France, in contrast, had no public health infrastructure in place after World War II. They had a network of mostly labor- and employer-backed non-profit insurance companies with premiums paid through payroll fees. Gawande notes: “Today, [the French] Sécurité Sociale provides payroll-tax-financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds.” Switzerland, which Gawande notes had a robust private insurance industry, got to universal coverage in 1994 when it required “every resident to purchase private health insurance and provided subsidies to limit the cost to no more than about ten per cent of an individual’s income.”
Each country arrived at universal health care by improving on its unique system.
Despite our unruly political context, large numbers of Americans can agree on things. The mobilizations to prevent the repeal of the Affordable Care Act showed the power of concentrated citizen action even in a money-soaked political system. Now is the moment to push hard on advances likely to have broad public support.
Updated August 22, 2017, to clarify that ACA rules prohibit charging older people more than three times the amount charged to younger people.
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