Seven years after the passage of the Affordable Care Act, Presidenat Donald Trump and the Republican-controlled Congress have launched a long-promised effort to repeal and replace the legislation.
So far, this initiative is getting off to a rough start; the health care reform bill unveiled last week is meeting with ferocious opposition across the political spectrum. The fault may be partly in the slipshod quality of the bill. But the difficulties of the reform effort also might point to the fact that truly good solutions to the challenges of accessible and affordable health care are nearly impossible to find — at least not without trade-offs that some would find intolerable.
It’s certainly hard to call the Affordable Care Act a success story. Insurance premiums have been rising, access to health care has not increased nearly as much as had been hoped for, and promises that people who want to keep their insurance policy or their physician would be able to do so belong in the political Hall of Infamy. Not surprisingly, Obamacare has remained somewhat unpopular, with many Americans consistently supporting its repeal. Blaming this merely on Republican propaganda, as many Democrats do, is wishful thinking.
But there is plenty of wishful thinking on the Republican side as well — for instance, that “patient-centered” or “consumer-centered” health care based on greater flexibility, transparency and choice would fix most of our problems.
Certainly, some proposed innovations, such as the ability to purchase insurance across state lines and to have portable policies from job to job, would benefit many Americans; it is also likely their impact would be limited. Transparency about the price of health services may not be as easy to accomplish as it sounds. Hospitals have a deeply entrenched system in which the costs of emergency care for uninsured patients with no ability to pay are spread to the insured. To change that would require a major shake-up.
Even without the cost-sharing, reliable estimates of health care prices may be difficult to give upfront. Medicine is full of uncertainties. Complications might arise; previously undiagnosed issues might be uncovered in the course of treatment or surgery. And even when the costs are known, patients and their families are often not in a good position to negotiate. Selecting the best treatment or deciding whether to get a test that carries medical risks is stressful enough without having to weigh the financial aspects as well. Most people in that position will probably prefer to let the insurance company handle matters.
Conservatives and libertarians often argue that there’s no reason markets should not work for health care the way they do for all other goods and services. But as much as I share the belief that markets and freedom of choice are best, health care is unique in some crucial ways: Very often, the alternative to purchasing it is death or disability. In what other area would people be willing to pay an exorbitant sum for a service or product that has less than a 50 percent chance of being effective? It is no accident that medical services often cited as examples of the markets’ ability to lower costs without insurance — breast implants or vision-improving eye surgery — are optional.
We did not have free markets in health care before Obamacare; conservatives who tout the freedom not to buy insurance rarely mention that under Ronald Reagan-era federal law, hospitals do not have the freedom to turn away indigent patients. Trump-era efforts to fix the system might solve some problems and create new ones. In the future, health care reform might become the new third rail of politics.
Cathy Young is a regular contributor to Reason magazine and Real Clear Politics.