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Five Things I think About the Next Phase of Health Care Reform

By Jay Want, MD, CIVHC CMO

This is not the end of Obamacare; it’s the beginning.

In a surprising move, Paul Ryan pulled the American Health Care Act, the Republican ACA repeal and replace bill, last Friday. It had become clear that there was no movement to the left or the right that would garner enough votes to allow passage in the House. Even if it had passed in the House by moving right, much of that movement was likely to be stripped out in the Senate, where the Republican majority is slimmer, but no less internally conflicted. The president has stated he is moving on to other issues like tax reform and infrastructure building.

So you might think that health care reform on the federal level is done for now. Whether that is true or not, it is also pretty clear to me that there is still a great deal of work to do to stabilize and improve the ACA. Cost constraints are still lacking, and insurance marketplaces at the state level are still suffering from shrinking insurer participation. While coverage has vastly improved under the ACA, affordability remains elusive if you don’t qualify for a subsidy.

Where are we going next? Some (including me) are hoping that this opens the door to real bipartisan negotiation.

Here are five things I observed from this last round of negotiations:

  1. The Freedom Caucus has a literal interpretation of the phrase “repeal and replace”. All the rhetoric about removing Obamacare “branch and root”? Turns out it wasn’t simply rhetoric for them. They believe that Medicaid expansion to childless adults must be removed entirely, because it is enabling able-bodied citizens to get care without working for it.
  2. Loss aversion works. One of the truisms of behavioral economics is that fear of loss is about three times as motivating as desire for gain. Thus, some people didn’t like the Affordable Care Act until they faced the possibility that they would lose coverage if it was repealed. For the first time in years, public approval of the ACA is greater than disapproval.
  3. Trying to sneak legislation through in the age of Twitter is like trying to sneak to the bathroom in your pajamas through Grand Central Station. Hiding stuff so you don’t get criticized for it doesn’t work. Nor does speeding up timelines for the same purpose. We may have to do this a few more times before people get it, but the old days of passing legislation that hasn’t been dissected under a microscope I think are gone. There are too many smart people out there with time on their hands and a Twitter following to feed.
  4. The emerging centrist view is that we need to maintain coverage for everybody who has it now, but get to cost containment to make the system sustainable. In a previous post, I talked about the hard truths that both sides are avoiding by blaming the other guy. But what do we do to control costs? The conservative answer is market forces, and the progressive one is government regulation. Neither one has a great track record when it comes to health care.
  5. And there is no guarantee the next move is toward bipartisanship. Winston Churchill said, “Americans will always do the right thing—after exhausting all the other possibilities.” If the last twenty years teaches us anything, it’s that governing from the extremes doesn’t work very well. So you’d think that the next move would be to try to govern from the center. But this is one of those Clayton Christiansen moments. Christiansen says that the winners of the last game are unlikely to be the inventors of the new game, since the new game displaces the old one.

Both parties have had the chance to be in the majority and the minority in the last two decades, and both have gotten pretty good at the existing game. It will take a sea change to find a new game that rewards centrist compromise. Here’s hoping we exhaust all the other possibilities sooner rather than later.

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