Breaking the Health Care Logjam

If you can believe their public statements, there is agreement among Republican Senators that certain parts of the ACA should be repealed. Yet they allow their disagreements over new features to get in the way of the consensus that supposedly does exist.

Here are some suggestions on how to break the logjam so that all Republican Senators can support a bill that partially fulfills the promise to repeal Obamacare without adding features which some of them can’t accept. There are at least six major components to the ACA:

1. A bunch of really foolish taxes, such as a tax on tanning and a tax on medical devices.
2. Mandates for employers and individuals to purchase health insurance.
3. Rules governing various mandates for insurance policies to cover.
4. Tax credits to subsidize insurance purchases for individuals.
5. More than 100 agencies to help regulate the health care of free citizens in a free society. The worst is IPAB (”the death panel”).
6. Medicaid rules and subsidies to states.

Reading proposed bills, especially ones which repeal or modify existing laws, is always an adventure. Let me cite a clause in the proposed Senate health care bill being debated now: 

“by striking subparagraph (B) and re-designating subparagraphs (C) and (D) as subparagraphs (B) and (C), respectively.”

There are dozens of such references to the current ACA or to other statutes, so that reading the new bill becomes a daunting task.  That aside, it seems to me that Republicans should be able to agree on certain changes to the six categories.

1. All or most of the ACA taxes should be repealed. If new taxes must be instituted (say, for reconciliation,) I suggest a payroll tax designated as the AHCA tax. A level of around 0.25% each to employees and employers should be adequate to replace all current ACA taxes. The idea is to simplify and to spread the cost among all taxpayers so they are constantly aware of how much it costs. The current ACA taxes can vary a lot from year to year, whereas a payroll tax would be more stable.  That is, or should be, the conservative way to tax.
2. Eliminate the mandates to purchase insurance. If generous subsidies are not enough to coax people to buy insurance, they should do without it. If employer mandates must remain in some form, replace the hard thresholds of numbers of employees with sliding scales, so that no business is hit with an enormous financial penalty for hiring one more employee.  Surely, even liberals can see the wisdom of that change.
3. Eliminate as many mandatory coverage features as Republican legislators can agree on.
4. For now, leave the tax credits alone unless 50 Senators can agree on changes.
5. Get rid of IPAB for good. Eliminate as many other of the ACA agencies as possible.
6. For now, leave the Medicaid subsidies to the states alone, unless 50 Senators can agree on changes. The irony is that with no action, they will expire soon anyway. This seems to be one of the hardest issues to deal with. But, in the next year or two,  the Democrats will have no choice but to make a deal or else see the subsidies go away. The leverage resides with the GOP. This issue need not stand in the way of the other reforms and passing a bill now.
7. There is an issue not expressly part of the ACA which should be dealt with here. Medicare (not Medicaid) should be enhanced to include appropriate custodial care (in home, if possible) for the elderly. Today, that is covered somehow by Medicaid with onerous conditions requiring forfeiture of assets. Cut the crap and make that part of Medicare. If it must be paid for with a new tax, increase the Medicare payroll tax to cover the actuarial cost of this benefit. It should be no more than 0.5% each to employees and employers. Much political hay has been made trying to scare Medicare recipients about this issue with regard to Medicaid funding. Let’s take away that threat. It would be extremely popular and a huge political victory for the administration with little downside.
8. If it is possible to include a ban on funding for the criminal enterprise known as Planned Parenthood, do so. But do not let the whole bill fall on that issue. There are probably a few other features which could be included, but again, they should not be allowed to sink the bill.

Subsidies and Politics:

Clearly, any reduction of subsidies in the ACA to any group of recipients will lead to cries of murder by the left. Of course that is ridiculous, but it is reality that they will say so. Even President Trump has called for kindness. It was with a heavy heart, that I suggested we accept that reality and for now, leave the subsidies alone.

There is no easy solution to the question of how much help to give various groups to acquire health insurance. With any rationally designed pricing, there will still be many who cannot afford health insurance. The cost will have to be subsidized by taxpayers, not because it is the right thing to do, but because it has become expected in our democracy. No amount of tears and protests by libertarians or other free market advocates is going to change that. These principled opponents can only decide if they want the determination of those subsidies in the hands of Pelosi and Schumer or Ryan and McConnell.

Leveraging Medicare and Medicaid:

Here is one more idea I have which I throw into the mix. I have not studied its implications, but something like it might be worth considering. It is not a recommendation but an idea to debate.

1. Leverage Medicare and Medicaid (M&M) without going to “Medicare for all,” which would be single-payer. There are a few goals:
   
   1. Use M&M as a backstop to the risk that catastrophic insurance poses to insurance companies.
   2. Use M&M as a backstop to the risk that insurance companies take by guaranteeing continuous membership in risk pools, regardless of adverse changes in health and removing lifetime caps on coverage.

2. Medicare is already available to younger citizens if they become sufficiently disabled. It could satisfy the above goals by setting suitable eligibility criteria and premiums:
   1. Compute an actuarially sound premium for a moderately healthy 60 year old (say) to enroll in Medicare or Medicaid.  Add 10% to that and call it X.
   2. Private insurance should cost substantially less than X for most people. Let insurance companies price the impact of pre-existing conditions, catastrophes, and continuous lifetime coverage into their own premium models.
   3. If no private company is willing to insure someone for less than X, allow them to buy the Medicare or Medicaid policy for X.
   4. All these private policies would include continuous lifetime coverage, so anyone who is insured at age 30, still gets to stay in that age-adjusted risk pool for 35 years for well under X. So this is not an excuse for insurance companies to game the system.
   5. Belaboring the obvious, a healthy 50 year old would never have an incentive to buy into M&M for a premium of X.

3. In this way, M&M would provide a baseline for adequate coverage. Private companies can offer more or less coverage in their policies and let the marketplace dictate the correct policy for any individual to buy.
4. Likewise, businesses which provide insurance will still be able to negotiate better deals with insurance companies than individuals and thereby enhance employee true compensation at a discount.

If you can believe their public statements, there is agreement among Republican Senators that certain parts of the ACA should be repealed. Yet they allow their disagreements over new features to get in the way of the consensus that supposedly does exist.

Here are some suggestions on how to break the logjam so that all Republican Senators can support a bill that partially fulfills the promise to repeal Obamacare without adding features which some of them can’t accept. There are at least six major components to the ACA:

1. A bunch of really foolish taxes, such as a tax on tanning and a tax on medical devices.
2. Mandates for employers and individuals to purchase health insurance.
3. Rules governing various mandates for insurance policies to cover.
4. Tax credits to subsidize insurance purchases for individuals.
5. More than 100 agencies to help regulate the health care of free citizens in a free society. The worst is IPAB (”the death panel”).
6. Medicaid rules and subsidies to states.

Reading proposed bills, especially ones which repeal or modify existing laws, is always an adventure. Let me cite a clause in the proposed Senate health care bill being debated now: 

“by striking subparagraph (B) and re-designating subparagraphs (C) and (D) as subparagraphs (B) and (C), respectively.”

There are dozens of such references to the current ACA or to other statutes, so that reading the new bill becomes a daunting task.  That aside, it seems to me that Republicans should be able to agree on certain changes to the six categories.

1. All or most of the ACA taxes should be repealed. If new taxes must be instituted (say, for reconciliation,) I suggest a payroll tax designated as the AHCA tax. A level of around 0.25% each to employees and employers should be adequate to replace all current ACA taxes. The idea is to simplify and to spread the cost among all taxpayers so they are constantly aware of how much it costs. The current ACA taxes can vary a lot from year to year, whereas a payroll tax would be more stable.  That is, or should be, the conservative way to tax.
2. Eliminate the mandates to purchase insurance. If generous subsidies are not enough to coax people to buy insurance, they should do without it. If employer mandates must remain in some form, replace the hard thresholds of numbers of employees with sliding scales, so that no business is hit with an enormous financial penalty for hiring one more employee.  Surely, even liberals can see the wisdom of that change.
3. Eliminate as many mandatory coverage features as Republican legislators can agree on.
4. For now, leave the tax credits alone unless 50 Senators can agree on changes.
5. Get rid of IPAB for good. Eliminate as many other of the ACA agencies as possible.
6. For now, leave the Medicaid subsidies to the states alone, unless 50 Senators can agree on changes. The irony is that with no action, they will expire soon anyway. This seems to be one of the hardest issues to deal with. But, in the next year or two,  the Democrats will have no choice but to make a deal or else see the subsidies go away. The leverage resides with the GOP. This issue need not stand in the way of the other reforms and passing a bill now.
7. There is an issue not expressly part of the ACA which should be dealt with here. Medicare (not Medicaid) should be enhanced to include appropriate custodial care (in home, if possible) for the elderly. Today, that is covered somehow by Medicaid with onerous conditions requiring forfeiture of assets. Cut the crap and make that part of Medicare. If it must be paid for with a new tax, increase the Medicare payroll tax to cover the actuarial cost of this benefit. It should be no more than 0.5% each to employees and employers. Much political hay has been made trying to scare Medicare recipients about this issue with regard to Medicaid funding. Let’s take away that threat. It would be extremely popular and a huge political victory for the administration with little downside.
8. If it is possible to include a ban on funding for the criminal enterprise known as Planned Parenthood, do so. But do not let the whole bill fall on that issue. There are probably a few other features which could be included, but again, they should not be allowed to sink the bill.

Subsidies and Politics:

Clearly, any reduction of subsidies in the ACA to any group of recipients will lead to cries of murder by the left. Of course that is ridiculous, but it is reality that they will say so. Even President Trump has called for kindness. It was with a heavy heart, that I suggested we accept that reality and for now, leave the subsidies alone.

There is no easy solution to the question of how much help to give various groups to acquire health insurance. With any rationally designed pricing, there will still be many who cannot afford health insurance. The cost will have to be subsidized by taxpayers, not because it is the right thing to do, but because it has become expected in our democracy. No amount of tears and protests by libertarians or other free market advocates is going to change that. These principled opponents can only decide if they want the determination of those subsidies in the hands of Pelosi and Schumer or Ryan and McConnell.

Leveraging Medicare and Medicaid:

Here is one more idea I have which I throw into the mix. I have not studied its implications, but something like it might be worth considering. It is not a recommendation but an idea to debate.

1. Leverage Medicare and Medicaid (M&M) without going to “Medicare for all,” which would be single-payer. There are a few goals:
   
   1. Use M&M as a backstop to the risk that catastrophic insurance poses to insurance companies.
   2. Use M&M as a backstop to the risk that insurance companies take by guaranteeing continuous membership in risk pools, regardless of adverse changes in health and removing lifetime caps on coverage.

2. Medicare is already available to younger citizens if they become sufficiently disabled. It could satisfy the above goals by setting suitable eligibility criteria and premiums:
   1. Compute an actuarially sound premium for a moderately healthy 60 year old (say) to enroll in Medicare or Medicaid.  Add 10% to that and call it X.
   2. Private insurance should cost substantially less than X for most people. Let insurance companies price the impact of pre-existing conditions, catastrophes, and continuous lifetime coverage into their own premium models.
   3. If no private company is willing to insure someone for less than X, allow them to buy the Medicare or Medicaid policy for X.
   4. All these private policies would include continuous lifetime coverage, so anyone who is insured at age 30, still gets to stay in that age-adjusted risk pool for 35 years for well under X. So this is not an excuse for insurance companies to game the system.
   5. Belaboring the obvious, a healthy 50 year old would never have an incentive to buy into M&M for a premium of X.

3. In this way, M&M would provide a baseline for adequate coverage. Private companies can offer more or less coverage in their policies and let the marketplace dictate the correct policy for any individual to buy.
4. Likewise, businesses which provide insurance will still be able to negotiate better deals with insurance companies than individuals and thereby enhance employee true compensation at a discount.