Repeal of Obamacare, ironically aka the Affordable Care Act (ACA), is finally in the works in D.C. As with anything significant, there be dragons, but the worst danger of repeal is in the cowardice and charlatanry of Congress, especially of congressional ‘leaders’. (See, for instance, the current ‘repeal’ bill in the House.) True repeal will require courage, a commodity in very short supply in D.C. All the same, the dragons should not be ignored.
The problem with repeal – actual repeal, I mean – is that it would, as Obamacare itself did, force millions of people to new health-care plans, thus converting many existing medical conditions to pre-existing for purposes of the new plans. As temptingly simple as ‘clean’ repeal may seem, that's not a good outcome. Rand Paul, in an uncharacteristically sensible moment, proposed that the new law should extend the ACA's prohibition against uprating or denial of coverage due to pre-existing conditions, or some similar protections, for two years past enactment. That should be enough time for the transition, and the idea is far better than permanent extension, so far so good.
But repeal must also deal with the fact that individuals (via the exchanges and Medicaid, which Obamacare expanded) and states (via Medicaid) have made plans relying on the current system. Naive of them, perhaps, but it does place a moral burden on Congress not to just yank the rug out. Changing Medicaid to a ‘per-enrolee’ block grant to states might have some merit, at the risk of encouraging enrollment-gaming (this means you, California), but it could help states to pick up the slack of transition with less perversity and expense than in the current system. Maybe. Wherever government is involved, trouble begins, but shrinking government will require incremental battles and here we have a great start. (The Trump Administration's war against the ‘administrative state’ is also a good start (god speed!), but that's a topic for another day.)
Following repeal of the ACA (caveated and tweaked as above), the most important things that Congress can do to ‘replace’ it are to:
- Allow people to buy their health-care insurance from anywhere, nationwide, that they can find it, so ending the current state-by-state (and, in some cases, county-by-county) nature of the market;
- Reform or repeal the pre-ACA tax advantage for employer-provided health-care insurance, or more precisely the tax disadvantage for self-purchased insurance;
- Allow robust medical savings accounts, possibly tax-exempt or partially so; and
- Reform medical liability law to reduce the risk to providers (e.g., doctors, hospitals, manufacturers, and their insurers) of outrageous jury-ordered medical jackpots, and (I dream) require judges and, especially, juries to take better account of the relevant medical science. No, your baby doesn't have Down Syndrome because the obstetrician misused his forceps, your ovarian cancer probably (almost certainly) wasn't caused by talcum powder (and talc has nothing to do with it in any case), your polycarbonate water bottle didn't give you man-boobs (it was your diet, dummy, and a little exercise wouldn't hurt), and your headaches and rashes aren't caused by radio waves. Sorry, and good luck, but go home.
Anyway, I would do as many of these things as politically possible in a single bill, because the idea of a ‘Phase 2’ (as President Trump promises) has, historically, been a loser; once Congress can say that they ‘did something’, they chicken out and stubborn up and refuse to do anything more. President Reagan learned that lesson from TEFRA in 1982 (Congress promised future spending cuts that never materialized), and Bush 42 learned it – again – in 1991. (Actually, I don't think that GHWB learned anything from either experience; he was too busy patting himself on the back for his ‘statesmanship’ in making the deal, and butt-hurt that conservative voters held him to account.) No honest conservative should ever make that mistake again.