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Fixing “Ryancare”

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The recent Congressional Budget Office report on the Obamacrare revamp crafted by Congress under Paul Ryan’s leadership puts a heavy kibosh on the chances that bill has of becoming law. Whether right or wrong in its projections of 24 million Americans ending up uncovered a few years out should the law pass, the projection can’t help but resonate in the political sphere. Americans have tasted government directed health insurance, thanks to Obamacare, and aren’t going to voluntarily go back. That was probably part of the Democrats’ intention in pushing it through and holding it in place for the duration of the Obama presidency. But it’s done and people rarely give up perceived benefits voluntarily. That’s why entitlement programs, once passed, never seem to get undone.

Given that, the best solution now is to rethink Ryancare and couple it with a conversion of the Medicaid program into a buy-in system of last resort. Based on a sliding premium scale (no cost for the indigent, as is currently the case anyway) it could offer insurance to everyone at a basic level, freeing up private insurers to do their thing in a more robust marketplace via competition across state lines, health insurance portability between jobs and other free market enhancements (including tort reform, health savings accounts and medical service and cost accountability systems to empower consumers).

The resultant two-tier system would address the concerns of many Americans that everyone should be covered, while allowing the private markets to grow, prosper, compete and offer better and cheaper options than today to those who want and can afford that. The pressure to expand service levels and make the “government option” equivalent with what can be bought on the private market will be substantial, of course, and, likely, will grow over time so we’d need to build into the legislation safeguards against willy-nilly expansion. Of course, even these can be removed once the political pressure becomes too great. Democracies are like that. But if we’re going to fix Obamacare and keep our word to those Americans who chose Republicans in the last elections, we have to come up with a fix that can be enacted. And the best bet for that now is to carve out some common ground with those on the left who oppose changing Obamacare at all because they fear it will gut the concept of universal coverage. A government option that gives people the ability to buy into a program like Medicaid can plug the last hole in the dike through which support for repairing Obamacare has been dribbling away.  It just doesn’t seem likely that the Republican plan as currently written, as fiscally sound as it may be, is going to get through today’s storm of demands, recriminations and political interests so Republicans are going to have to do something to address the 24 million uninsured projected by the CBO.

Voters will demand it and, if they don’t get what they want, they will repay Republicans in future elections, the first of which is only two years away.

CBO could be wrong, of course, but that doesn’t matter. The only thing that counts now are perceptions and right now the CBO report dominates the general perception of the Ryancare plan.

Living in Israel for a time some fifty years ago, I saw a similar approach. All Israeli citizens and new immigrants got a Kupat Holim card which entitled them to free health services at government clinics around the country. The service wasn’t great (think the Veterans Administration!). You waited a long time on benches in crowded areas with everyone else, kind of like today’s private Urgent Care facilities, and you got doctors who weren’t top notch. Those who were offered their services for a fee in the private market and if you had a serious problem and wanted immediate attention and could afford it, you went to one of them. They operated in parallel with the government health care service, creating their own free market. I don’t know what the current Israeli system is like but a two-tiered approach like that might be the only rational way, at this point, to meet the very widely held concern in this country that EVERYONE must be covered by health insurance, period.

We’ll have to deal with the near certain political pressure to upgrade the government buy-in option to private sector service levels in the future, and with the inevitable stress such an upgrade would put on private markets, down the road of course. But for now, the issue is to meet the GOP promise to fix Obamacare and do it in a way that preserves President Trump’s pledge to voters, however fiscally ill-advised it may have been at the time.

Ultimately what we’re facing is a political problem now, not merely a policy problem, and it’s unlikely the GOP can convince the country (not, at least, a significant part of it) to go back to what existed before Obamacare without providing assurances that universal coverage is part of the new package.

The Republican approach, that cheaper, more abundant options made possible by a more robust private marketplace will make healthcare accessible to everyone who wants it, isn’t going to be enough anymore. People want guarantees of universal healthcare coverage, not merely a system that makes it possible if everyone makes a decision to participate. The CBO is right that there will always be some who don’t choose to sign up until they actually need the coverage — but Americans just don’t cotton to the notion that people who choose foolishly should end up suffering from the dumb choices they make.

About Stuart W. Mirsky

Stuart W. Mirsky, a former New York City official who last served as Assistant Commissioner for Operations in the New York City Department of Health and Mental Hygiene before retiring in 2002, wrote a column, "The Rockaway Irregular," for The Wave, a south Queens based weekly, for more than a decade (until Hurricane Sandy changed the equation). He is an original founder of the Rockaway Republicans, one of the most active Republican groups in southern Queens, and author of a number of books, including The King of Vinland's Saga, an historical novel of the Norse in 11th century North America, A Raft on the River, a memoir of Holocaust survival, and Choice and Action, a work of contemporary philosophy addressing the implications of relativism and nihilism for our moral beliefs.

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