Republicans and Democrats disagree about the role of government; the trade-off between individual freedom and societal good; and about money and taxes. These long-standing disagreements play out repeatedly on the national stage, and today, health care is front and center. On our present course, these disagreements will turn our health care system upside down every time we vote to change party control of the White House and the Congress.
Seven years ago, congressional Democrats voted for the Affordable Care Act without a single Republican vote. They did so believing it was necessary to ensure everyone had access to affordable care through a federal mandate to purchase insurance. Employers were mandated to provide coverage for their employees. And, insurance companies were required to offer plans that covered essential health services. People with pre-existing conditions would be included in the same insurance risk pools with everybody else. Unfortunately, despite the name, affordability remains elusive.
When House Republicans voted in May to repeal Obamacare, without a single Democratic vote, they concluded that it is wrong for the federal government to require people to buy health insurance. The mandates on individuals to buy health insurance, on employers to provide health insurance and on insurance companies to cover people with pre-existing conditions would be repealed.
As Senate Republicans come to terms with being unable to unite their members around a repeal and replacement bill, there is talk of simply voting to repeal Obamacare without a replacement. Without a replacement, patients, insurers, health care providers, employers and premium payers would be in limbo, with adverse consequences for fully one-fifth of the American economy.
Republicans say that without limiting the amount of money the federal government pays for Medicaid and for high-risk people with pre-existing conditions, the federal government might have to increase taxes or take on more debt to pay for health care. And they would be correct. Democrats say that by limiting the amount of money for health care, the poor and those with pre-existing conditions might not have access to the medical care that they need. And they, too, would be correct.
And while it would be an exaggeration to characterize this dispute as being just about money, it is important to keep in mind that all the money America spends on health care comes from us — the taxpayers and premium payers. Our federal and state income taxes pay for Medicaid, the program that provides health insurance for people living below a threshold of the federal poverty limit. Our payroll taxes pay for Medicare, the program that provides health insurance for people over the age of 65. And if we have private health insurance, we are paying premiums to an employer or an insurance company.
If Republicans and Democrats could agree to work together, here’s a three-step compromise to consider:
1. Democrats would need to yield on a single-payer public option. And Republicans would need to yield on their desire for a private-sector solution. Some of our health system would be financed with taxes, and some of our health system would be financed with insurance premiums and out-of-pocket cost sharing. Not coincidently, this tenuous compromise is in place today.
2. Combine Medicare and Medicaid into a single public program for seniors and people living below the federal poverty limit, financed with a combination of payroll and new federal taxes. Republican state legislators will like the efficiency of eliminating 51 state Medicaid programs and getting state government out of the health insurance business. Democratic legislators will like the consistency of eligibility, access and quality across all 50 states. Formulating rational Medicaid polices at the federal level is not possible when the financing of the program is shared with 50 very different state governments.
3. For those under age 65 and living above the federal poverty limit, access to private insurance is what you have today, and what is most practical going forward. Importantly, both parties will need to compromise and allow thoughtful regulation of the private insurance markets to ensure principles of fairness and inclusion, especially for people with pre-existing conditions and people at the lower end of the income scale. At the same time, a compromise should respect the deeply held American value of “individual freedom” which causes people to oppose federal mandates.
Undoubtedly, many readers will take exception to one compromise or another. However, without compromise, we ensure continued uncertainty in health care from one election to the next. That uncertainty is bad for America, life-altering for patients and families, and unsustainable for health care providers and insurance companies.