Monday, December 26, 2016

Replace and Repeal

Obamacare is dead! Long live Obamacare.

The Republican Party will control all branches of government in January, and has a stated purpose to repeal and replace Obamacare (properly the Affordable Care Act). 

Repealing Obamacare may not be as easy as  it sounds, and replacing it has many risks and uncertainties.

Both parties agree the system needs reform. That is about all they agree on.


Obamacare care is much more than a piece of legislation, it is now six years of regulation and innovation, and is intertwined through the health care system. There is no unpeeling of an apple.

There has been much to like about the intentions of Obamacare, even if the design and  implementation were  often wretched. The latest regulations on Medicare physician payment run to 2171 pages of  complex and convoluted regulatory excess.

Obamacare gets a good grade on intentions, but not so good on design or operations. Still, a full operational repeal is not possible, too many changes are ingrained into the system for a full.


Timing is everything. I just finished reading House Speaker Paul Ryan's  A Better Way plan including the health care section. Whether or not Ryan is popular with his own membership, his health plan lays out the key ingredients of any GOP or conservative health reform plan. I am not impressed.

Leading the list are Health Savings Accounts (HSAs) and the interstate sale of health insurance policies, neither of which are likely to provide the salvation promised. 

Health care markets do not work like the markets  for buying a shirt,  a car or a head of lettuce. The HSA idea may be overrated as a tool of salvation, but good for the affluent.

The interstate sale of insurance policies saves money only if the insurers under price their products, and that can only happen for a few years before something bad happens. This is much like several of the ACA exchanges. I fear interstate sales will empower 1-800-Lousy-Policy companies, a consumer nightmare in the making.

The replace program promises cost savings through consumer choice, a profound misreading of how consumer find and use health care.

Like most GOP initiatives, the plan works well for the affluent and not  so well for anyone else. And when the GOP talks about “protecting Medicare,”  I know we are in trouble. The pro-life GOP will find a way to punish Medicaid recipients, count on it (and punish hospitals in the process).

Curiously, the GOP plan for patient protection  includes many features – wait for it – of Obamacare, just without the details. Lots of buzzwords though.

Perhaps I am a bit too cynical, but I think not. The Trump administration will be a wild ride on many counts, and not the least of it will be health care.