Of all the issues our nation faced in the past decade, who would have supposed health care would sit at or near the top of the list and would become a potent political wedge issue? Although undeniably important, health insurance hardly sizzles in the public mind like the economy, the national debt, immigration, abortion, gender equity, tariffs, defense funding or the U.S. role in the world. How did health care come to be one of the most divisive issues we face?
The Democrats opened battle by passing the Affordable Care Act, or ACA, in 2010. But partisan troops continue to skirmish about it. Federal health care policy is haphazard and chaotic with no consensus in view. You should blame both parties for a major failure in leadership. Indeed, the health care debate has been so contentious that it helped kill bipartisanship in Washington, D.C.
When Barack Obama became president in 2009, he enjoyed both a Senate and House controlled by his party. He quickly put them to work on health care as his signature issue.
Democrats saw lack of access to health coverage as the big problem. Republicans, on the other hand, claimed it was primarily an affordability issue. It’s a good deal of both, and a bipartisan bill would have addressed both concerns. But brushing Republicans aside, the Democrat majority ignored affordability and passed the Affordable Care Act on a party-line vote, thereby igniting the partisanship wildfires which no one has been able to quench since.
The threshold challenge to establishing a health insurance program is to get an underwriting pool of participants with lots of healthy people in it to offset costs incurred by those needing medical care. But many healthy souls — often the young who feel immortal — don’t want to buy health insurance. To overcome this, the right-leaning Heritage Foundation proposed that everyone should be required to have medical insurance.
The ACA included such an individual mandate. It also required insurance companies to insure everyone — called “guaranteed issue” — without significant differentiation in cost based on health conditions. Preexisting conditions were required to be covered. These requirements are consumer-friendly but very expensive.
The ACA created Healthcare.gov, the federally-operated exchange where qualifying individuals can get coverage tailored to their needs and, if eligible, obtain generous means-tested federal subsidies.
Notably, the ACA allowed states to expand their Medicaid programs to everyone below certain income levels rather than just the disabled, blind, and pregnant mothers. The feds would pay a whopping 90% of the cost. Red state legislatures resisted, but voter initiatives have recently defied them by choosing expansion in Idaho, Nebraska, Maine and Utah.
As soon as the ACA was passed, the wheels started coming off. It was too complex, expensive and administratively burdensome. You couldn’t necessarily keep your existing insurance policy or your doctor as claimed.
In 2017, Republicans took over the White House and control of Congress, and quickly stripped the centerpiece individual mandate out of the ACA. They would finally “repeal and replace” the ACA, a leading talking point for conservative talk shows and congressional campaigns since the ACA passed. But incredibly, Republicans had no replacement legislation, no plan, nada! First the House and then the Senate failed to repeal and replace. (Remember Sen. McCain’s famous thumbs down signaling he would vote against repeal and replace, which incurred vociferous presidential wrath.) Although wounded and hated by many, the ACA lives on.
Modern Healthcare recently opined the Trump “administration has withheld cost-sharing subsidies; ended the individual mandate; backed the law’s repeal in court; slashed outreach funding; promoted skimpy health plans; undercut the small-group insurance market; discouraged Medicaid enrollment by adding work requirements; and weakened rules against discrimination of all types.” The editorial claims the nation’s uninsured rate and uncompensated care are therefore increasing. Families and employers have turned to high deductible, high co-pay plans, which discourage getting needed medical care. Many basic, life-saving drugs are now unaffordable for many.
Our great nation has a half-gutted health law and no roadmap of where to go next because Democrats and Republicans cannot agree on a bipartisan way forward on health care. With real leadership, we might have had bipartisan agreement in 2010 and 2017 or even today. Sadly, Republicans and Democrats leaders alike failed to grasp those great opportunities.
Greg Bell is the former lieutenant governor of Utah and the current president and CEO of the Utah Hospital Association.