Guest Commentary: Reforming health care still elusive

Guest Commentary: Reforming health care still elusive


Repeal and replace the Affordable Care Act, aka Obamacare, has been much in the news. As a candidate, Donald Trump assured us in September 2016, “On my first day, I am going to ask Congress to immediately send me a bill to repeal and replace Obamacare.” He followed up a month later saying, “You’re going to have such great health care at a tiny fraction of the cost. And it’s going to be so easy.” A month later, Trump pronounced, “When we win on Nov. 8 and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare.”

While Trump was masterful in terms of appealing to the people, to anyone with a sophomoric understanding of health policy, Trump’s statements were unrealistic as confirmed by subsequent events. Shortly after taking office, and with nothing on his desk nor on the immediate horizon on Feb. 27, President Trump said, “Now, I have to tell you, it’s an unbelievably complex subject,” he added. “Nobody knew health care could be so complicated.” In short order, at least in terms of health care, Trump went from megalomania to prescience.

In July, the Senate voted and failed to pass the Better Care Reconciliation Act -- BCRA, also known as “TrumpCare,” or to its opponents as “Make America Sick Again.” In September, the Senate again failed to get the needed votes to pass the Graham-Cassidy-Heller-Johnson repeal and replace bill. Nor is any other bill under serious consideration on the legislative horizon.

So, why after seven years of vowing to repeal and replace Obamacare, which many of it its supporters acknowledge is far from perfect, have the Republicans who control the House of Representatives, the Senate and the Oval Office failed to deliver on their promise? The answer is, as the politicians discovered, it’s not easy. Any repeal bill had to take into consideration who was included, what benefits were included, the role of the marketplace, the extent of government involvement, how much would it cost and how and who would pay for it.

Yes, many voters have been justifiably critical of Obamacare because of its inadequacies and supportive of efforts to “repeal and replace.” But many of those same voters wanted a replacement that would not only provide access but be comprehensive and affordable. The average citizen doesn’t care whether the end product is called improved Obamacare or Trumpcare, so long as it’s superior to anything they presently have.

Not surprisingly, it quickly became evident to many patient advocates, health care providers, insurers and consumers that the Senate repeal bill was seriously flawed. More than 300 advocacy groups, including the American Medical Association, the American Hospital Association, American Nurses Association, American Cancer Society, American Heart Association, Blue Cross Blue Shield, America’s Health Insurance Plans and AARP, opposed the bill. Said another way, the Washington Post was unable to identify any health related associations that supported the measure.

Interestingly, as this unfolded, public support for Obamacare increased not because it got better, it didn’t, but because the proposed remedy was worse than what it was supposed to replace. Over 30 million people faced losing coverage, and insurers would be able to charge higher premiums to those with pre-existing conditions affecting about half of adults under the age of 65. Nor would insurers have to cover “essential services,” such as pregnancy, maternity and mental health care.

Block grants to states would reduce Medicaid funding, which just shifted the problem to the states, albeit with less funds. Not only the poor but every middle class family needing long-term care in the future for themselves or their parents potentially faced bankruptcy. Already stressed rural hospitals, which receive support from the ACA and Medicaid, would receive reduced funding. Also, it didn’t help that reducing health expenditures was seen by many as a subterfuge for tax cuts for the wealthy.    

The above explains in part why the Republicans couldn’t immediately follow through on their promise to “repeal and replace” Obamacare on day one nor to this date. While they will be criticized by some for not following through, they also faced a significant backlash if they had replaced Obamacare with their Ebenezer Scroogecare bill. In the end, maybe some were swayed by the Pottery Barn Rule, “If you break it, you own it.”

Thomas O’Rourke is Professor Emeritus of Community Health at the University of Illinois.