The debacle of the repeal-Obamacare movement left the president and the Republican Congress ruminating about the terrible lessons they had learned from the defeat — mainly that neither ever had a health plan or even a clue about how to frame one.
Both the moderate and right-wing elements who trooped to the White House to be won over by the self-proclaimed greatest negotiator in the history of the world came away muttering that President Trump seemed not to have the lamest grasp of the issues — neither the real problems of Obamacare or how it worked nor the changing elements of the hastily written Republican replacement. All that stuff about Trump hating policy, details and briefings on any subject was really true.
For Americans of every hue and rank, the lesson was clearer. The tumult over Obamacare and the need to repeal it was never a crusade but a charade. It was all political, never over principle, never about better coverage, lower costs and better service for the sick and the lame. It was all about denying a legacy to Barack Obama. Each of the more than 60 votes in Congress since 2010 to repeal Obamacare was a ruse, or else the bills would have included at least the outlines of a system that would replace it.
The nutty defeat, or hasty surrender, of the American Health Care Act of 2017 summons no memory of a worse political blunder by either party. The great failing in the passage of the Affordable Care Act in 2010 was that few Americans understood exactly what it did, and the opponents quickly filled in the narrative, based on polling of phrases that angered people, like doctors and patients not being able to make decisions about their care, death panels, slashing Medicare and government medicine.
But people quickly understood the GOP bill, helped by the analysis from the Republican-directed Congressional Budget Office. It would cut 24 million people from insurance rolls, cut taxes of the very rich, make insurance costlier for millions of the neediest people and begin to shrink Medicaid coverage, and not just for the childless adults added by Obamacare. Unless you were rich or had stock in a pharmacy company, medical equipment maker or insurance company, you could identify nothing in the plan that would help you.
What the GOP bill did was keep the basic Obamacare plan, eliminate taxes on the rich and corporations, and monkey with tax subsidies to make premium and deductible costs higher instead of lower and force the whole thing into collapse over time. Polls showed that in three weeks from its introduction to its collapse public support fell below 15 percent.
If there was an ounce of public faith behind the movement, Trump and congressional leaders would have said, OK, if this doesn't work let's take another look at how to fix it, instead of declaring that Obamacare is here to stay and Democrats will own it when it collapses. (It won't.)
That's how great legislation happens. Medicare and Medicaid started with Kerr-Mills (our Wilbur Mills) in 1960. It let the states determine who would be eligible for federal-state help getting health insurance. It was a total flop, mainly owing to the lassitude of the states (Arkansas took it for nursing home patients and no one else), and in 1965, goaded by President Lyndon Johnson, Mills produced Medicare and Medicaid.
Obamacare is not hard to fix. Trump guessed at its central shortcoming: Insurance premiums and out-of-pocket costs are so high, even with subsidies for low-income families, that people still find it unaffordable. Twenty million got insurance through Obamacare, but an equal number can't or won't access it. Some 10 million eligible for Medicaid in the 19 Republican states that shunned it will come into the fold before long — Kansas maybe this spring.
Obamacare — indeed any successful insurance program, like Medicare, old-age, disability and unemployment insurance — depends upon the young and healthy joining the pool rather than waiting until they are sick. When they don't join the pool, insurance companies have to raise premiums for the sickly who join. Obamacare imposed a tax for remaining outside the pool to energize them into joining, while the GOP plan imposed a stiff tax only when they finally joined the pool and made it payable to the insurance company, not the treasury.
One solution, always embraced by the insurance industry, is a stiffer tax than Obamacare's to remain out of the market. A better one is to improve the tax credits to make premiums more affordable for families of modest means and to raise the threshold for help beyond 400 percent of poverty. Perhaps some ingenious Republican has a different idea about how to get around the problem of the young and vigorous staying outside the market. They could invoke the public option, discarded back in 2010, at least for rural communities in Arkansas and other states that few insurance companies enter.
They could fix it all in weeks, Trump could keep his promise of near universal coverage, his party could claim to have overcome Obamacare, Democrats would shrug, and America would be great again. If it were a matter of public interest.