Un-wrecking the train

Despite the confident predictions of “unnamed sources” that there would not be a Republican repeal and “replacement” of WhatshisnameCare until at least the fall, the GOP has rolled out a substantial chunk of what they have dubbed the “American Health Care Act.”  Evidently this deconstruction of the ACA dumpster fire is planned to take place in three chunks: the things President Trump can do on his own, the things that can be accomplished via “budget reconciliation” (which is how the thing got passed in the first place in the dead of night on Christmas or New Year’s Eve, can’t recall which), and the things that will require getting over a Senate filibuster one way or another.  At the moment it’s not getting a very warm reception, due in part to this multi-phase structure, and as usual the Republicans are not doing the greatest job of communicating about it, so it’s hard to say what the good and bad points are right now without knowing if one is looking at the finished product or just one of the three stages.

Frankly I don’t like the idea of doing anything in “stages” unless they’re all meant to be executed simultaneously, OR the first part is to give me everything I’m after and we’ll get to your stuff later.  Which never happens.  Thus far it’s taking a lot of heat from points all across the conservative spectrum, from establishment types to Trump diehards and everywhere in between, who are voicing real concerns about important points they are not seeing addressed in the bill as it has been presented (I think it’s at ReadTheBill.org, in a dig at Nancy “Pass it to find out what’s in it” Pelosi).  And of course the usual Democrat suspects are out whining about it for the usual nonsensical reasons.  I’m not going to waste time on their brainless chatter.

To be blunt, I am not sold on the concept that we “can’t” ever repeal an entitlement and that we “have to” replace this septic tank with something that smells a little less foul.  However, I do acknowledge that even the act of repealing this monstrosity in the first place, even if we do immediately plug in a better (or even slightly less bad) version, will be a groundbreaking step in itself, and we are undeniably in an “anything will be better than this” situation right now.  That said, there are some things that, in my opinion (which I don’t think is far off the mark for most Trump voters) are sine qua non for whatever the replacement plan ends up being and I for one will be looking to these points to judge whether or not the replacement is any kind of improvement, or just a politically expedient band-aid.  I want to preface this by saying that I have no love for the insurance companies.  I consider them cronyists of the worst kind and they were all-in on WhatshisnameCare as originally conceived because they loved the idea of having a captive clientele and the government to backstop whatever ridiculous premiums they had to charge.  So if any of what I’m suggesting falls on their shoulders, tough bananas cupcake, you backed the wrong horse and it’s time to pay up.

So this is what I firmly believe MUST be addressed in the repeal action:

Individual mandate: First and foremost the government must not be allowed to force people to buy health insurance on pain of fine or other penalty.  They tried to ease us into this with a little prick of a couple hundred bucks the first year or two before socking it to those not in compliance with a tax penalty of several thousand dollars at this point.  And it’s telling that people like the small business owner at the debate between Ted Cruz and Crazy Bernie STILL were opting to go without insurance and pay the fine.  It’s that bad.  Now, this is one of the things that has already been dealt with, sort of–the IRS has been directed not to bounce tax returns that do not confirm that the taxpayer had health insurance, which in effect nullifies the mandate, but I won’t be comfortable going without until I see the penalty removed from the books entirely.

Subsidies: The big lie.  The real hidden cost of this whole shakedown.  It infuriates me every time I see the insipid healthcare.gov commercials with the smiling millennials bragging about how low their premiums are because the government is picking up half the tab or more.  That’s not how this works, children.  First of all, that doesn’t mean your premiums are low, that just means you’re not seeing them, just like you don’t see your tax bill because it’s withheld from your paycheck.  You are deliberately being kept ignorant of what you’re paying or what is being paid on your behalf.  Second, and most horrifically, you’re dumping the cost of your overpriced health insurance (not even health care, just insurance) on your children and grandchildren and you’re bragging about it.  Someone has to pay for that sooner or later and guess what, it’s not “the 1%.”  Meanwhile those horrible awful mean nasty insurance companies who the left cried would always jack up people’s rates or cancel their policies or whatever are raking in cash hand over fist (although it can’t be working out too well for them as more insurers pull out of more exchanges every year–must be pretty bad when you can’t even make a profit on a customer base that has no choice but to buy your product).  Subsidies MUST end or be severely curtailed.  Right now the buzz in the Republican plan is about tax credits rather than direct subsidies–I need more details but I like the sound of this a lot better already.

Real choice, real competition: This has in part to do with allowing insurers to sell across state lines and in part to do with letting people decide what kind of coverage they want again.  If someone wants bare-minimum catastrophic coverage in case a meteor falls on them they ought to be able to buy it and pay accordingly.  If someone wants to pay for full service coverage then I question their judgment but okay, go for it.  Men should not have to pay for mammogram coverage any more than women should have to get prostate treatment covered.  And nobody, NOBODY, should be forced to pay for anyone’s abortions.  Or birth control for that matter–but if you want a plan that covers that, you’re welcome to get one.  Yes, the government requires you to have insurance to drive a car.  It does not require everyone to get full coverage for a vehicle with a $35,000 Blue Book value even if you’re driving a run-down old clunker worth two grand on a good day.  As for competition across state lines, or otherwise removing barriers to entry for smaller upstart insurers (which of course the big players don’t want), nothing will bring prices down faster.

Those are what I see as the big three that must be addressed.  I’d like to mention briefly a couple more things I would consider in the “very nice to have” or “strong improvement” or “this can make up for a lot of faults” category:

Get the government as far out as possible: Kind of a no-brainer and a bit more of a pipe dream, but really, especially where the federal government is concerned, the further the government gets its hands away from individual health insurance decisions as well as health care itself, the better things will work out for everybody.  Seriously, even far lefties like Screamin’ Howard Dean have acknowledged that Sarah Palin was right, WhatshisnameCare would inevitably involve “death panels” just like socialized medicine in other countries like Canada does–the government eventually reviews your situation and decides whether you’re a justifiable expense or whether they write you a script for morphine and send you home to die.  The expression among foreign doctors in these horrible systems is (and I want it to remain) “In America there is always hope.”  As Bill Whittle put it, an experimental treatment with a 20% chance of success might never happen in a socialized system, but given a 20% chance versus a 100% chance that going home and vegging on a morphine drip means I’m dead, I and most Americans at least want the option to roll the dice on that 20% chance or that 10% chance or even that one in a million chance.  Ideally I’d like to see a massive reform and rollback of Medicaid at the same time, but we’ll take the steps forward where we can get them.

Encourage pay-as-you-go: This is huge.  I wouldn’t call it a dealbreaker by any stretch of the imagination because I can see it might be hard to write into any legislation, but in recent years there has been an explosion in what are called “concierge services,” a fancy way of saying you pay in cash rather than charge it to insurance and you get a discount for it.  And by a discount I mean a massive discount–procedures and tests that will bill for several thousand dollars to insurance can cost you just a couple hundred bucks if you pay out of pocket.  This is an example of market forces at work and it needs to be encouraged on both ends, possibly by allowing the patient some kind of tax deduction (which health savings accounts can be if they are implemented properly) and likewise allowing the doctor a writeoff for a portion of the difference between the insurance price and the cash-on-the-barrelhead charge.  Also, letting capitalism work its glorious magic will just drive the Democrats up a wall and that’s a mighty compelling fringe benefit.

So I and many others are in “wait-and-see” mode for what this new plan will contain.  The President himself and Speaker Ryan’s office have confirmed that the bill that has been greeted with a lot of justifiable skepticism is only part of the full plan, so while I am not inclined to take Paul Ryan at his word, I am inclined to believe President Trump knows who his customers are and knows what they want to see.


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