In healthcare: The debate is dead. Long live the debate!
U.S. politics has been roiled for over a decade by disputes over the Affordable Care Act (ACA, or “Obamacare”). However, three recent developments really mean that the big debate is effectively over. The disputants are haggling over marginal details, not battling over great principles.
However, this change offers the opportunity to switch to a different debate. To worry less about health insurance and more about the delivery of care.
Let’s begin with the three big developments:
First, in oral arguments over the case of California v Texas, Chief Justice John Roberts and Justice Brett Kavanaugh (and perhaps Justice Sam Alito) strongly telegraphed that they wouldn’t strike down the ACA even if they find that the law’s hollowed-out individual mandate is unconstitutional.
Second, the November elections likely ended chances for Medicare for All (M4A), where the federal government would pay for all healthcare. Sen. Bernie Sanders’ M4A bill had its day during the Democratic primary debates. President-elect Biden and other candidates urged less sweeping approaches, like a “public option.”
But one could still have imagined robust Democratic House and Senate majorities passing M4A and President Biden signing it. But Democrats barely hung on to their majority in the House, and Republicans will hold between 50 and 52 Senate seats.
Plus, Sen. Joe Manchin (D-W.Va.) said: “We can’t even pay for Medicare for some and to go Medicare for All, we can’t take care of those who are depending on it right now.” Add to this that many centrist Democrats blame their party’s election losses on the progressives and their strident policy agenda — including M4A.
And third, Republicans have essentially endorsed the ACA’s central organizing principle — guaranteed insurance coverage for those with pre-existing medical conditions.
Upon signing a presidential executive order in September, President Trump declared: “The historic action I’m taking today includes the first-ever executive order to affirm it is the official policy of the United States government to protect patients with pre-existing conditions, so we’re making that official.”
But, the ACA had already done that, and the GOP had focused its messaging on coverage for those with pre-existing conditions as early as 2017.
Whether or not to guarantee coverage for those with pre-existing conditions was the central divide in the 2010 ACA debate. The ACA combined guaranteed issue (insurers must sell policies to anyone, regardless of their health status) and modified community rating (insurers can’t charge higher premiums to those with costly illnesses).
In 2010, Republicans opposed the ACA’s guaranteed issue-plus-community rating out of fear that such a policy would destabilize existing insurance markets (as had happened in several states).
They argued that forcing insurers to sell policies to people after they became sick was equivalent to requiring fire insurance companies to sell policies to people after their houses were already burning. There was also concern that the ACA was promising more care for more people without increasing the resources available to deliver on that promise.
But covering those with pre-existing conditions is now Republican mantra, and their differences with the Democrats are more about how to accomplish that rather than whether to do so. (Plus, with Joe Biden in the White House, undoing the ACA is off the table for four years.) The two parties may still think themselves far apart on health insurance policy, but their actions and rhetoric suggest otherwise.
For Monty Python fans, it’s now the People’s Front of Judea versus the Judean People’s Front.
However, this affords a remarkable opportunity to shift the debate in healthcare toward the supply side — how we actually produce and deliver care, rather than how we pay for it. COVID-19 has forced us to re-examine delivery: telehealth, medical licensure, regulation of healthcare professions and institutions, the processes for approving new drugs and devices, and more.
We’ve spent nearly a year figuring out how to stretch our resources farther and how to use them more efficiently. Allowing a doctor in Oregon to treat patients in Virginia during his off hours via telemedicine is one example.
The end of the old debate offers us a powerful opportunity to refocus on this more productive, less partisan set of questions.