Latest posts by Jane M. Orient, M.D. (see all)
- Setting National Health Priorities: Trump and Climate Change - December 21, 2017
- The Opioid Disaster—Who Benefits? - October 11, 2017
- John McCain and the Partisan Farce on “Healthcare Reform” - August 8, 2017
Congress should take a vote on simply repealing ObamaCare. Republicans should be forced to go on the record to show how they keep—or renege on—their campaign promises.
Just in case it should pass, both Democrats and Republicans should be working on a series of “restore” bills to debate, one issue at a time, immediately after repeal. Members would have a chance to advocate for any parts of ObamaCare that they favor. However, the actual effects of the provisions should be named, instead of the purported good intentions. It is time to look at the nuts and bolts, not CBO guesstimates of enrollee counts.
Judging by the objections that have been raised to repeal, the American Medical Association (AMA) and others ought to be in favor of many of the following:
1. Keeping insurance UNaffordable: Reenact ACA provisions that outlaw catastrophic coverage and require a long list of benefits and guaranteed issue/community rating. Reenact the tax on insurers that was suspended for this year.
2. Restricting access to care: Reenact restrictions on physician-owned hospitals or other entities that compete with big hospital chains. Continue requirements on insurers that allow them to keep their costs down only by narrow networks, nonremunerative fees, or other measures that limit availability. Reenact the Independent Payment Advisory Board (IPAB) so it can limit services that can be paid for, and thus cap Medicare expenditures as Baby Boomers flood the system.
3. Protecting the managed-care cash cow (Medicaid): Continue without limit the huge federal subsidies to the Medicaid expansion states so they can continue to pour money into plans that keep childless, able-bodied adults on the welfare (Medicaid) rolls without necessarily providing any medical care. This protects the program from the fiscal restraints imposed by states’ inability to print money.
4. Taxing the sick and the rich: Reenact all the taxes on medical devices, tanning salons, etc. This will help keep care unaffordable and limit availability. Also reenact the “Cadillac tax” on overly generous insurance benefits, and the added taxes on “rich” people. They are popular with the non-rich, and since they are not indexed to inflation they will help extract revenue from more and more people as time goes on.
5. Taxing the healthy, the young, and the responsible: Continue guaranteed issue/community rating so that the costs of older, unhealthy people who did not buy insurance until they “needed” it can be shifted to low-risk people who maintained continuous coverage and would have much lower premiums if they were actuarially fair.
6. Reducing jobs, especially full-time jobs: Reenact employer mandates to restrict job creation and augment down-sizing by making it much more expensive to hire people.
7. Taxing people who can’t afford to buy insurance: Reinstate the individual mandate. The penalty has been criticized for not being high enough to “encourage” people to pay insurers rather than the IRS. They have to pay the insurers more than the IRS, but at least they would have an insurance card, whereas the IRS provides no benefits. Congress could increase the penalty. It could also consider allowing people to deposit that amount into a Health Savings Account (HSA), since uninsured people also receive medical care and have medical bills to pay. This would require lifting the requirement to combine an insurance plan with the HSA. But that gets into “replace” rather than “restore.”
8. Funding navigators, websites, and advertising for Exchanges: While it would seem unnecessary to pay to help people “shop” and encourage them to buy, when there may be only one product (or none) to “choose” from, people who have been hired to perform these functions would become unemployed if ACA is repealed.
9. Subsidizing economically nonviable products: When a marketplace is unstable because regulations make it impossible to make a profit, the only way to keep suppliers in it is to pay them with federal dollars from taxpayers or creditors. The sellers will continue to have enrollees who find the product affordable because somebody else is paying most of the cost.
10. Forcing everyone to fund contraceptives and abortion: Although many Americans consider these to be immoral, especially contraceptives that may have an abortifacient effect, others consider social benefit to override individual conscience. From the purely economic perspective, there seems to be a short-term benefit of having fewer children to support. In the longer term, there are also fewer taxpayers and workers.
It is time for supporters of ObamaCare to make their case for the parts that they like and have bills ready to introduce immediately if repeal should pass. If they do not favor these various provisions, how can they logically be opposed to repeal?
Once Congress focuses on the problems with ACA, it can begin to think about replacing them—with freedom, instead of more of the same.