Restless Natives

The natives are getting restless.

Here we are only a few weeks into the Trump regime and already some of his early supporters are beginning to waver. Where they ask is the repeal of the hated Obamacare? Where is that domestic infrastructure plan? Where, for that matter is any policy that isn’t foreign?

Repealing Obamacare is going to be a fun thing to watch for those of us who would prefer it stay in place. For the record I was never a big fan of the Affordable Care Act, I have always thought that the best way forward was some sort of single payer plan such as “Medicare For All”, but that simply marks me as some sort of looney fringe crank. Everyone, we are told, knows that good Americans will never settle for a government plan — this despite almost half of all healthcare dollars spent in the country originate in the government’s coffers.

Never mind facts.

Those restless natives on the extreme right of the Republican Party really really want the ACA repealed right now. They just don’t care about the consequences. The rest of the party is slowly realizing that such an abandon is a political suicide track. Hence the recent and very noticeable reticence of party leaders to say too much other than they are “advancing” with their repeal plans.

Advancing, perhaps, but not very far.

The problem the Republicans have is that any repeal and credible replacement of Obamacare will hurt their core voters much more than it will hurt Democratic core voters. This nasty little conundrum was overlooked during all that huffing and puffing in the Obama years. It was easy back then to look tough and right wing when there was no accountability. Now things are a little different.

For instance: the hated mandate has to go in order to pander to the far right. It is seen as a massive government intrusion into the happy liberties of the general public. It especially is reviled by young healthy folk who don’t feel the need to have health insurance. After all they’re healthy. But that mandate is the essential method to lower premium costs for older and sicker folk. By mixing young healthy people with older sick people the insurance companies can average down the premiums they charge. Taking those younger healthy people out of the pool automatically raises the premiums older sicker people will have to pay.

Older sicker people are the core of the Republican voter base. Younger healthy people tend to be Democrats. You can see the conundrum.

By following through on their promise to get the government off their backs, Republicans will hurt their own voters far more than they will hurt anyone else. This is not good politics.

So a great deal of the hesitancy in putting forward a repeal plan is that the Republicans need to sort out how to deal with this self-inflicted wound.

One alternative that is much in vogue is to have the government expand the availability of health savings accounts. HSA’s have been on offer for a long time but have restrictions that make them relatively unpopular. In particular they are associated with very high deductible plans. This means that the people who can afford to use HSA’s are higher income earners. Indeed HSA’s have become a popular tax avoidance scheme for the rich, who can accumulate high HSA balances and then use them to pay for exotic and only vaguely health related stuff like a day at the spa. Extending the use of HSA’s looks a lot like yet another Republican gift to the rich, so there is a lot of discussion about how to limit them. And, obviously, putting too much a limit on them reduces their value in mitigating the damage repeal of the ACA will do to Republican voters.

Now you can see why repeal is going to take a while.

Another mitigating method much debated in Republican ranks is the creation of what are called “high risk pools”. These have been around for a while too, many states had them prior to ACA. A high risk pool gathers together all the sicker people in a state or region and then creates a special insurance plan for them. The premiums are higher, after all they are higher risk pools, but those higher premiums can be reduced via a government subsidy. While this doesn’t exactly sound like getting the government off the backs of the great folk of America — a subsidy is a subsidy after all — it does help with the political problems the Republicans face with those young healthy voters who objected to being coerced into buying insurance. But those voters aren’t Republicans. The people in the high risk and higher premium pools are. So we are back to square one.

Besides the high risk pools that existed before the ACA were hardly a success. Few states made a real effort to make them work because of their cost, and the restrictions put on them were so tight that many had negligible sign up.

So the Republican party will have to chug along for a while and have this intense and divisive internal debate until it confronts that stark facts of insurance: the bigger and wider the pool the lower the cost of insurance. Plus the less complicated the variety of plan the simpler and cheaper the administration. The overhead ascribed to Medicare is vastly lower than that ascribed to most private sector plans. Insurance facts ought to be obvious: single payer is cheaper, less onerous, and simpler. The civilized world already knows that.

But this is America with its Republican party.