ACA Repeal/Replace: Progressives Face Moral Dilemma

[Bob Butler 54]

(07-28-2017, 04:45 PM)Warren Dew Wrote: Only 3 of the 49 voted for "skinny repeal" because they hoped something better would emerge.  Probably most to all of the other 46 actually preferred "skinny repeal" to any of the alternatives offered.

I mean, seriously:

- Medicaid expansion untouched, which gave the moderate Republicans everything they could hope for.
- The individual mandate, hated by all, repealed.
- The employer mandate, which prevents creation of full time entry level jobs, repealed.

The exchanges are already in a death spiral; tanking them a little faster or a little slower won't make much difference.

Warren’s comment above is illuminating.  Twisting it somewhat, Obamacare can be seen as a bunch of mandates.  The individual must contribute.  The employer must contribute.  The government must contribute.  The Republicans seem to be against contributions.

If we keep the current health care system structure, we’ve got many payers.  Obamacare is to a great extent an attempt to balance all these payers into something that works for the People.  These mandates are an awkward kluge in part because the system is an awkward kluge.  There are too many people who have profited off the existing system that don’t want to lose their milch cow.  In order to get the many contributors contributing in a vaguely effective way you have to apply crowbars in awkward places.

Obamacare isn’t ideal.  It’s a kluge.  I don’t think anyone thinks it doesn’t need really big adjustments. There is just no agreement on what the adjustment is.

I think a base difference is whether one sees health care insurance as insurance.  The way insurance generally works, everyone with a car buys auto insurance.  Everyone with a building buys fire insurance.  Often, these are required by the government.  The general concept is that everyone contributes.  Those that are lucky in a given year cover the expenses of the unlucky.  You set prices so the unlucky survive without their lifestyle being destroyed.

In health care, under a multiple payer system, with different rules for how everybody contributes or doesn’t, you can always point a finger and say this isn’t fair, or that isn’t fair.  If you’re full time, the company pays, if not, and  you’re under 65, you pay, but over the government pays.  That’s just the simplest high level summary.  You can point a finger and say this detail isn’t right or that isn’t right really easily.  Somebody will always complain.

And if you’re into the unravelling memes, the knee jerk response is to cut taxes, assume that the government will muck it up, that you want to reduce services to the people, and since you’ve got yours, it’s a fine thing to raise a finger at those who don’t.  Yes, if you’re an individual, you hate the individual mandate.  Yes, if you’re an employer, you hate the employer mandate.  Yes, if you’re Republican, you hate government doing anything.

Meanwhile, the thought of going single payer, of solving the problem like everyone else is solving the problem, is anathema.  You want to get rid of individual and employer mandates?  Sure, let’s get rid of individual and employer mandates.  Everybody else has.

So, yes, Obamacare is a kluge.  Repeal it.  Replace it.  Alas, the Republicans have the congress and they seem more interested in the interests of the wealthy and healthy than providing health care for the American people.  The people who have been in car accidents should pay for the car accidents?  The companies that have had fires should pay for the fire damage?  That’s not how insurance works.  We should all contribute and all benefit should the time of need come.  If we’re going to aim for a vaguely fair system, the contributions should come out of the general tax system rather than an ad hoc mess.