A Momentous Day for Health Reform

Today is momentous for two reasons: 

• It’s the 7th anniversary of the passage of the Affordable Care Act (ACA) - a fact which I continue to celebrate.
• It’s the day that House Republicans could vote to replace the ACA with the American Health Care Act (AHCA), a bill which will lead to millions losing their health insurance and decimate the Medicaid program, while providing a significant tax cut for our most wealthy citizens – a possibility which I cannot celebrate.

While the ACA is imperfect, the AHCA is not true reform. I would love to find a bipartisan path forward. As I reflect on the past 10+ years that I’ve been working on health reform, there are so many lessons learned. For today, I’d like to highlight this excellent piece, The Lessons of Obamacare: What Republicans should have learned, but haven't, that was done by Sarah Kliff and Ezra Klein at Vox, which details those lessons, and points to the considerations needed for real health reform. If you don’t have time to read all 9500 words of their article, we’ve excerpted key points from their 7 lessons below. Enjoy!

Lesson 1: Everything in health care is a painful trade-off. Own it.

• Any government health coverage expansion involves a series of trade-offs, decisions that will inevitably anger one constituency or another.
• Provide robust health insurance plans, for example, and you need to spend more money — if you don’t, you must decide to cover fewer people. Provide skimpier coverage, and the price tag of a health insurance expansion goes down, but people get frustrated with their high deductibles and copays.
• The American Health Care Act would change the rules of the individual market to advantage people who are younger, healthier, and higher-income — but disadvantage people who are older, sicker, and poorer.

Lesson 2: Bipartisanship — can’t live with it, nearly impossible to do reform without it

• Obama put a lot of effort in trying to gather bipartisan support for the ACA but was shot down every step of the way.
• Mitch McConnell, the leader of the Senate Republicans, explained his strategy. “We worked very hard to keep our fingerprints off of these proposals,” he said. “Because we thought — correctly, I think — that the only way the American people would know that a great debate was going on was if the measures were not bipartisan. When you hang the ‘bipartisan’ tag on something, the perception is that differences have been worked out, and there’s a broad agreement that that’s the way forward.”
• McConnellism — which Democrats have now learned from and adopted — leaves the US political system in a fragile place. The Senate is a body that, at least under its current rules, typically requires compromise for anything to get done. But if the minority accurately diagnoses compromises as counter to their political interests, then nothing can get done.

Lesson 3: If you change the health care system, you own it

• Republicans remained unified in their opposition to the health care law, even as millions gained coverage.
• Polarization almost certainly played a role in keeping Obamacare unpopular, as Republican legislators shifted rightward and saw little political benefit in compromise.
• Americans didn’t seem to recognize what parts of Obamacare worked, but they could see exactly which parts of the health care system didn’t seem to function well. And one of the challenges the Obama administration constantly confronted — one that held back the law’s popularity — was that anything bad that happened in the health care system got blamed on Obamacare.

Lesson 4: Benefits might not get popular, but they are very hard to take away

• For reformers of all ideologies and all approaches, this is the hardest fact of health reform: We aren’t starting from scratch. Any system you build needs to be a compromise with the system we have — a system that provides insurance to more than nine in 10 Americans, a system that employers know how to navigate, a system the medical care industry has designed itself around.
• Now, Obamacare is the status quo. Tens of millions of Americans rely on it for health insurance they fear losing. This is the reality Republicans are facing, and quickly coming to fear. 

Lesson 5: Partnering with the private sector, and private insurers, can be risky — in a way expanding government-run programs isn’t

• The marketplaces, the focus of more publicity and promotion, have consistently underperformed expectations. The Medicaid expansion, meanwhile has proved more successful than anyone thought.
• There are risks to working with private partners. If they decide not to participate in an insurance expansion, there isn’t much the government can do except beg and plead.
• The Republicans will see if they, unlike the Obama administration, can turn an industry accountable to shareholders into a willing partner.

Lesson 6: Affordability doesn’t mean what Washington thinks it means

• Health reform, Obama promised, would “bend the cost curve.” The changes appear to have worked. System wide costs have been growing at their slowest rate in recorded history.
• The policies that control costs are the policies people hate most. The narrow networks and high deductibles are among Obamacare’s most-loathed features

Lesson 7: Prices are the fundamental challenge in American health care — and reform will remain an exasperating exercise until that changes

• The reason American health care is expensive is because when we go to the doctor, it costs more than when someone in another developed nation goes to the doctor.
• Other developed countries use price controls in medicine. The government negotiates with drug companies and device makers and doctors to set lower prices. The government is buying in bulk, and has the power to win those negotiations. These countries regulate medical prices akin to how they regulate the price of electricity or water: a service that everyone needs at reasonable price, but would face significant difficulty bargaining for on their own.