Sunday, February 12, 2017

Ride the Tiger - Health Care Edition

President Harry S. Truman and country singer Buck Owens both used a familiar ancient idiom – when you grab hold of a tiger letting go is dangerous.

The Trump administration and the Republicans in Congress have learned the same lesson the hard way, they jumped on the health care tiger and now they do not know what to do.

Where are We At?

The Republicans in Congress have discovered some hard truths about health care.

U.S. health care is complicated.

The Affordable Care Act is complicated.

Health care economics is complicated.

Budget politics is complicated.

Writing new health care law is complicated.

Keeping promises is complicated.

Pleasing 325 million people, or even a slice of that population, is complicated.

So all of the chest thumping and hollering about “repeal and replace” has so far turned into hollow noise, because doing something of substance is a lot tougher than shouting slogans.

What They Don't Know

In six years I have not encountered a Republican, either face-to-face or through their media presence, who sounded as if they actually knew what is in Obamacare and why. I suppose such people exists.

It is all about the slogans.

“Death panels!” “Illegal mandates!” “Crushing tax burdens!”

The U.S. health care system was complicated before the Affordable Care Act, and the overwhelming complexity of ACA made it much worse. Add to this thousands of pages of Obama-era regulations and there is a lot to know about the current health care system.

This cannot be fixed with slogans.

The GOP Menu (maybe)

Conservative think tanks and the GOP have been circulating the same ideas for decades.

Health Savings Accounts – good for the affluent, not so good for anyone else

Interstate sales of health insurance – does absolutely nothing for consumers, except expose them to lousy insurance plans - but good for lousy insurance companies and salesmen

“Market based” consumer choices – as in buying oncology is like buying a cheeseburger

Dump ACA subsidies, replace with tax credits (subsidies!)

Special treatment for Big Pharma – yes, Congressmen are for sale (both parties)

Block grant Medicaid – give Medicaid policy to Sam Brownback and Paul Lepage - wow

Send poor people back to Emergency Departments (which hurts hospitals)

So What Am I Saying?

The GOP does not have a coherent plan to replace the Affordable Care Act and may never have such a plan. There will likely be a repeal, total or partial, but the replace will be difficult.

The GOP might eventually have a plan to make Rush Limbaugh, the Koch brothers, the Tea Party and Fox News happy, sort of. Even that may fail.

The GOP has been blaming ACA for higher consumer costs (higher deductibles and co-pays) , and may replace ACA with a plan with – you guessed it – higher deductibles and co-pays,, including for seniors.

Repeal and Replace, or Partial Repeal and Partial Replace, or Reform and Repair, or ?????

On Super Bowl Sunday President Trump told Fox News that “repeal and replace” could take up to a year. Huuuge!

A few days earlier Rep. Jim Jordan, on the far right wing of Congress, said the total and complete and quick repeal of ACA was the only viable strategy. Soon.

In the last ten days or so “repair” has become a popular word, often in a phrase such as “reform and repair.” This implies that not all of ACA would be repealed, some of it would be repealed and new features would be added as a repair.

Ask ten Republicans in Congress and get seven or eight different answers. There is also squabbling about whether health care should be done before tax reform. The House majority and the Senate majority have different ideas, and the Senate majority is pretty thin.

So, the GOP has painted itself into a corner. The GOP could recover, stranger things have happened in Washington, but as of early February consensus is not looking either quick or easy, which makes near term legislation unlikely.

Legislative strategy

IF, repeating IF the GOP can agree on a plan, the various pieces and parts must through the legislative process. Some parts could move through reconciliation, others through the standard legislative process. This could cause a problem in the Senate.

The Longer Term

House Speak Paul Ryan has promised to”fix” Medicare.

There are ways to fix Medicare, but Ryan apparently has no clue. There are serious reform efforts already in motion to move Medicare from the original fee-for-service model to a more sophisticated value-based model, the legislation passed by bipartisan votes.

His approach is to turn Medicare into a for-profit play pen for insurers and doing tremendous damage to senior citizens. Wow.