Note to Republicans: be careful what you say you want….the dilemma of health care

There is a lot of wisdom to the old saying about being careful about what you wish for because you may get it. The Republicans have gotten their wish. They can now repeal Obamacare. By the time it is done they may regret it.

Most people, to some degree, perhaps with some qualifications, accept the idea that people should not die or get sicker simply because it costs too much for them to go to the doctor. For many people their objection with Obamacare is not that it does the wrong thing. They just think it does it poorly.

A beginning place is to consider what the Republicans cannot repeal. They can repeal money things with 51 votes in the Senate. But not everything is a money thing. Things like the individual mandate, no preexisting conditions, and premiums based on income and not on age or medical condition are all subject to filibuster and Republicans don’t have the votes for that.

They can repeal the subsidies that make insurance possible for many people. They can do anything that involves the use of federal money. If you simply repeal the subsidies you still have a law that says that everyone has to have insurance, a law that says no one can be denied insurance because of preexisting conditions, a law that says insurance premiums are based on the ability to pay and not age or health conditions. You would still have a law that says that insurance must still cover essential health conditions.

What you have is a disaster. Insurance companies will be legally obligated to do certain things in a system that has eliminated perhaps the primary mechanism to ensure they get paid for the insurance they provide. You have a recipe for death. Insurance companies would have to flee the market or die. The people depending on them will have no where to go. They will die.

There are basically 3 ways to pay for health services.

1. Governments pay through some kind of subsidy. In essence taxes pay for people to be insured.
2. Healthier people pay for sick people by the fact that they must carry insurance even if they don’t use it. Cheap people pay for more expensive people.
3. Hospitals and medical providers charge more to everyone to pay for the people that cant pay for care.

The ACA relies on 1 and 2. Those states that in particular have not expanded Medicaid find option 3 coming into play. If the government cant or wont pay enough, if there are not enough well people to pay for the sicker people, if the hospitals and doctors cannot charge enough to pay for the lack of the first two you have a system that strangles itself to death. Hospitals close, doctors leave and everyone is affected.

The Republican plan assuming that there eventually is one may not use the mechanisms that Obamacare does but if you accept it as a value that people should not die for lack of access to medical care they must seek to accomplish the same goals.

There has to be a way to pay for more expensive people or you must let them die. 21 million people have insurance that did not have it before. Taking away from 21 million people something so important as health insurance when you did not even win a majority of the popular vote for President is probably not the choice that every political party yearns for.

With a few votes, and using very little foresight other than the compulsion to satisfy political rhetoric the Republicans can take what already is a problem filled area and turn it into one of the greatest human disasters in this country. It will not be enough for them to win a political battle. They must win the battle of numbers and the numbers are no respector of political affiliation. As long as Barrack Obama was there to save them from themselves they could repeal the ACA endlessly. It never meant anything. The adult has left the room. The next time counts.

The Republicans are going to repeal everything they can repeal. They must replace the ACA with something (repealing the ACA without something in place to take its place given the Republicans track record of working together and coming to common agreement has got to stand as one of the stupidest ideas I have ever heard of). It must work out the same issues the ACA attempted to solve. Maintaining the ban on preexisting conditions without something like an individual mandate is going to be close to impossible. Selling insurance across state lines does nothing to address any core conditions.

People are going to be hurt. A lot of people are going to be hurt. And some, probably way too many, people will die.
Winning political capital is going to take first place over the welfare of the people that elected the Republicans.

Paul Ryan calls it “A better way.” If you believe that I have a bridge in Brooklyn I would like to sell you.

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