Senate Health Care Fix or Folly?

Despite campaign promises from then candidate Donald Trump as well as from incumbent and new members of Congress to repeal and replace Obamacare, now almost six months into the Trump presidency, Obamacare is still the law of the land. Progress, albeit slow, was apparent this week as the Senate passed their version of a replacement, following the House doing the same two months ago.

Are either if these bills a true fix or are they simply folly, rearranging the deck chairs on the Obamacare Titanic?

The Senate bill, depending on who you ask, is even less of a repeal than the House bill. Conservative pundit Ann Coulter calls it “Obamacare Lite." Then telling us how she really feels about it, calls it a “total disaster.” The media, and their political arm, the Democratic Party, have the opposite view. Senator Elizabeth Warren views it more like an Indian tomahawk, not scalping anyone, but far more deadly, “the health care bill is going to kill people.”

It can’t be both. Is it a watered-down version of Obamacare, the current health care plan revered by Democrats? Or is it draconian reform, the type promised by Republicans every two years when running for reelection?

Given that no one really likes the bill, is this an example of a good compromise one when no one gets what they want?

The Senate bill leaves much of Obamacare in place, tinkering with regulations, means testing, Medicaid expansion and a host of other details. The bill might be an improvement, the way an outside temperature of minus 20 is an improvement on minus 30, but it’s still darn cold.

At this point it’s not clear if this bill will even pass the Senate. Five of 52 GOP Senators oppose the bill as it stands. Senate Majority Leader Mitch McConnell can only lose two votes in his caucus because the chance of garnering any Democrat support is less than zero. After a round of horse-trading, threatening and cajoling, a new bill may emerge acceptable to the entire GOP caucus.

The problem is that if Senators Rand Paul, Mike Lee and Ted Cruz like the bill, you can be sure Senators Susan Collins, Lisa Murkowski and Cory Gardner will not like it and will vote against it. That’s the perhaps insurmountable problem facing Republicans, too much political diversity within their caucus.

It’s the Goldilocks and the three bears problem. On the Republican side the porridge will be either too hot or too cold. Not so for the Democrats. Regardless of the porridge temperature, every Democratic member of congress will say the porridge is just right and eat it. Which is how Obamacare passed despite those on the far left wanting single payer, knowing that Obamacare, while a step in that direction, was not their holy grail.

The House faces the same problem, moderates versus the Freedom Caucus. While a bill did pass the House, it was a preliminary step. I suspect many voted for it just to move it along, in the hopes that once the bill passed through the sausage-making machine, something tasty would emerge that they could enthusiastically support. If the Senate does pass a bill and it goes to conference, resulting in another lousy bill, there may be insufficient GOP support to advance it to President Trump’s desk.

Herein lies the challenge for the GOP. A full repeal, despite the desires of many Republican voters and despite repeated campaign promises, is a political nonstarter. Entitlements are almost impossible to take away, especially in advance of the midterm elections. Members of Congress are political creatures whose primary goal is not legislation, but reelection.

A full repeal, meaning peeling back the Medicaid expansion and coverage for preexisting conditions just won’t happen. Clone Ted Cruz or Rand Paul and put 60 of them in the Senate and Obamacare might be cleanly repealed. Otherwise we’re wishing for the impossible. In a world where Senators like Lindsay Graham and John McCain continue to be reelected, expecting the Senate to fully repeal Obamacare is a fool’s errand.

The only way in my opinion to pass this roadblock is replacing Obamacare with a two-tiered system. Something conservatives, moderates, and perhaps even a few Democrats could get behind. I’ve written about such a compromise creating two parallel systems.

Tier one is a Medicaid-for-all catastrophic coverage plan. Everyone eligible, no out of pocket costs, but bare bones coverage. Providing one of the holy grails of the left, “universal coverage.” Something a few Democrats might support.

Tier two is a totally free-market system for insurance. No mandates or essential benefits. An open, transparent and competitive market. Purchase the insurance you want and need, nothing more.

Two separate and distinct systems, each doing what it does best – universal coverage or free market. Rather than our hybrid system of trying to combine both, getting the worst of both and the best of neither.

Would something like this pass? More likely than an Obamacare-lite bill that satisfies no one and pisses everyone off. Another failed piece of legislation that this time will be hung around the necks of Republicans just as Obamacare was the noose around Democrat necks during their last three devastating electoral losses.

Finally, Republicans can squabble and pass nothing, leaving the status quo Obamacare slip-sliding into insolvency and implosion. Following the advice of Senator Lindsay Graham, "Just let Obamacare collapse, then challenge the Democrats to come in and help us fix the mess they created."

Great in theory. In practice the Republicans will be blamed. By everyone. The media and the left will blame Republicans since the collapse occurred on their watch. The right will also blame Republicans for failing to deliver on their campaign promises to repeal and replace Obamacare. All in all, a risky move, especially with not having the media to spin it favorably for Republicans.

Time for leadership. Voters gave Republicans the keys to the kingdom – White House, Senate and House. Time not to fiddle and fluster, but time for a grand deal. Let’s see if they are up to it.


Brian C Joondeph, MD, MPS, a Denver based physician and writer. Follow him on Facebook,  LinkedIn and Twitter.

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