The Upton bill scheduled for a vote in the House, which would give insurance companies the option of continuing for a year the health insurance plans they have just canceled, is the first significant Republican effort to reform instead of kill the Affordable Care Act. Of course, it has a major downside: The number of those populating the exchanges will be smaller, and less healthy, because the individuals who will most want to keep their plans are the ones insurance companies cherry-picked due to their good health. But the bill at least acknowledges the reality that Obamacare is here to stay.
Will it be the first of a series of steps to adjust the ACA? I doubt it. The zeal to trash and sabotage Obamacare is now deeply seated among Republicans in and out of Washington. That zeal has nothing to do with the botched rollout of HealthCare.gov or the broken promise of the president about the ability of everyone to keep his or her plan, much less the fundamentals of the act.
A good case study in this zeal comes from the Washington Post columnist Charles Krauthammer. In a recent column, “Obamacare Laid Bare,” he challenges the entire structure of the Affordable Care Act.
Krauthammer does not like President Obama any more than he likes green eggs and ham, as evidenced by the fact that he can’t help but make two references to Benghazi and one to the IRS in a column on health policy. He attacks the plan for throwing far more people off their insurance than it can possibly be signing up on the exchanges. He lays into the idea that those with individual health plans will now be forced to pay for coverage they do not need: “So a couple in their 60s must buy maternity care. A teetotaler must buy substance-abuse treatment. And a healthy 28-year-old with perfectly appropriate catastrophic insurance must pay for bells and whistles for which he has no use.”
Lost in this analysis is any sense of what the Affordable Care Act does and why, much less any link to the reality of what insurance is and what it does. Exhibit A in the latter case is the set of charges about the rank unfairness of forcing people to pay for coverage they do not need. My wife and I are a couple in their 60s—and we pay for maternity coverage, as we have for decades after we needed it, as part of our group insurance via my employer. When I was in my 20s, I paid—as part of my group insurance at a university—for all kinds of coverage for ailments that hit those in their 60s but were not at all relevant for me. That is what insurance offered to groups of people does.
That reality has always been true for those of us, the vast majority of Americans, who get their coverage through their employers. It is also true that for some very healthy individuals who have not had the ability to secure insurance through an employer or group, they could tailor their coverage to exclude items they would not need, or could gamble that they would not need. But for most—including many of those so privileged—the individual market has been a jungle.
Whether unemployed, working for an employer who does not provide insurance, or between jobs and no longer eligible for COBRA, individuals seeking insurance have faced a market where preexisting conditions—even as trivial as acne—might be enough to deny coverage, or to have coverage suspended when the insured gets seriously ill. Finding insurance on the market was its own nightmare even for sophisticated individuals, as I discovered some years ago when I was shopping for insurance for my able-bodied son, whose Ivy League degree did not bring with it a job that offered health insurance. I went on ehealthinsurance.com and found an impressive array of plans available to him at different price points. But once I got past the initial paragraph describing the basics, discerning what each policy actually covered and didn’t cover was virtually impossible. Comparison shopping to buy individual insurance was like buying a mattress, and there was no assurance, after purchasing a plan, that it would actually pay for all the costs that might result from a terrible accident or a devastating illness.
For every unfortunate story now of an individual losing his or her existing plan—each of whom will get replacement coverage, albeit some with higher costs—there are stories of those who discovered after it was too late that the coverage was not there when they needed it, or was canceled because of a real or imagined preexisting condition. Creating a base of coverage to protect those from disaster, to ensure that basics of insurance routinely made available to those of us in groups are there for those not in groups, is not some horror of big government run rampant but a rational and humane way to create basic national standards. Expanding the risk pool by adding the sick or potentially sick, who are now screwed, and those who have not bothered to get insurance despite the risk of accident or catastrophe, has a cost, but it is one worth paying.
And for those thrown off their insurance, for whom Krauthammer expresses deep concern, all will be able to retain insurance coverage, most at a net cost at or below their existing plans, without the holes in coverage they now have. For every one who will pay more, there will be many more who will get coverage for the first time, or who will be free from the burden of staying in jobs only because they need insurance, or who will be lifted from the burden of ultra-expensive COBRA coverage when between jobs and without incomes.
There is no excuse, period, for the president’s false comments about Americans remaining free to keep their coverage. And there is plenty wrong with Obamacare, partly because it was jerry-built to get around the early and implacable opposition of all Republicans in both houses to passing any health care bill, or to offer a single vote for the plan in return for adding constructive amendments. But the structure, built around expanding the risk pools, creating a fair marketplace of private insurers to enable competition to work, and premium support for those who can’t afford coverage, is precisely the one Republicans advocated in the 1990s and right up until 2009. In the supreme irony, it is the same structure Rep. Paul Ryan offers in his proposal for Medicare—call it Obamacare for seniors.
If you think about it, it would be in the interest of conservatives who believe in the magic of markets to make this system work. If it can be demonstrated that real competition in a real marketplace offers good services at lower overall costs, that adds powerful ammunition to the case for free markets. Let’s face it: The unrelenting opposition to all parts of the law, as reflected not just in critiques like Krauthammer’s but also in the more vapid and confused attacks by Sarah Palin and others, is far more about Barack Obama than it is about the structure and nature of the Affordable Care Act.