With the election of Donald J. Trump and Republicans firmly still in control of the House and Senate, we are, whether we like it or not, starting all over again on our tortured and very unfinished journey toward a health care system that is available and affordable for all our citizens.
This has been going on for more than 100 years. While other developed nations created more equitable and less costly (and, I would argue, equal in quality) health care systems we have steadfastly resisted the truth that our medical industrial complex works well for some, not at all for others, and costs way more than it reasonably should. So, after the Affordable Care Act’s noble effort to provide better access to care through a subsidized commercial insurance marketplace, we seem on the verge of blowing it up. I don’t think that will happen as quickly as promised. It’s a big, complicated law and it will take a complicated series of maneuvers to actually “repeal and replace” it. The new President doesn’t really have a replacement in mind. And his fellow Republicans in Congress have all sorts of proposals, most of them recycled free-market talking points about health insurance that have been tried – not all that successfully – at the state level. Expect to hear a lot more about those in the weeks to come.
Some of these ideas are worthy of consideration, if for no other reason, than we need to acknowledge we have tried a lot of things to bend the cost curve in recent years and they barely have budged it. (We got 20 million more Americans a health care plan, sure. But not enough has changed in terms of helping control costs. Perhaps nothing will. But we should be willing to consider all proposals.) You’ll be reading more about them on this blog in the weeks and months to come, if you are interested in exploring them further.
But it boils down to this (it always has): Are we capable of sustaining a thriving, for-profit commercial health insurance industry, a thriving for-profit pharmaceutical industry and a thriving health-care delivery system for a population that has equitable access to all three so that it too may thrive? All the proposals on the table, new ideas as well as the “good parts” of the ACA, should be considered.
One component that bears intense scrutiny and thoughtful reconsideration is Medicaid, the 50 year old program designed to get poor people access to health care. Medicaid, like it or not, has become a whipping boy that some states in recent years have purposely underfunded and undermined. This will be a major component of whatever comes next and it will — as it always has — be the key to the survival of our nation’s public, safety-net hospitals.
We should be open to a whole new approach on Medicaid. (Yes, even block grants, assuming – and this is a big assumption – that they aren’t being offered strictly for cost-saving reasons.) Perhaps there are some worthy experiments to conduct with the states along these lines. Among other things to consider: Why is Medicaid the payer for long-term care for the nation’s elderly and disabled? Shouldn’t there be a separate program for how to pay for nursing home care for those who can’t afford it? Why put these patients in competition for the same dollars with uninsured pregnant women and their children, or the day-laborer who can’t manage his diabetes and relies on the public hospital emergency room because the state says it can’t afford to put him on Medicaid?
Okay, everything back on the table. Except…..
There is one inviolable pact on which those of us who have pledged to equal access will not budge. We should muster all our energy and whatever political clout we have remaining to thwart, obstruct and litigate any plan at the federal or state level, where working people and their families living below the poverty level are purposely ignored and forced to go without the care they need.