Leonard Cohen and the ACA

Poet and musician Leonard Cohen passed away Nov. 7. Inarguably one of the most influential voices in popular culture, with a career that spanned nearly six decades, he captured very large concepts and constructs with a powerful economy of language. Watching the presidential election the following day, I couldn’t help but recall some of his more pointed lyrics — especially as applies to health care reform, version 2.0.

In a volume of selected poems he wrote, “Ring the bells that still can ring. Forget your perfect offering. There is a crack in everything. That’s how the light gets in.” Until the election, the health care “crack” wasn’t large enough to accommodate any efforts at reforming the ACA. Post-election, it is fair to say that the crack is now a chasm. Still, the question remains: What light — and how much of it — will actually get in?

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President-elect Trump has put forward a seven-point plan as his administration’s starting point. Paul Ryan and the U.S. House of Representatives’ Republicans have “A Better Way” (that is the actual name of their plan). Both begin with repealing the existing law. Politico reports that, “… leading advocacy groups [are] ready to wage ‘total war’ to defend President Barack Obama’s universal health care program and his domestic legacy.”

So, what does this all mean? Just days after the election, the president-elect opined that keeping the provisions prohibiting exclusions for preexisting conditions and for allowing those up to age 26 to remain on their parent’s plans should remain in place. As Mr. Cohen noted, “Even damnation is poisoned with rainbows.” Rather than accept that some existing ACA provisions might make it into a new design, the punditocracy pounced, pointing to a broken campaign promise to repeal and replace.

At this early stage of the discussion, if we strip away the partisan trappings, what is actually being proposed? Mr. Trump suggests that we must eliminate the individual mandate, modify existing laws to permit sales across state lines, allow individuals to fully deduct health insurance premiums, allow for wider adoption of HSAs, require price transparency from all health care providers and facilities, turn Medicaid into a block grant for the states and remove barriers to entry into free markets for drug providers.

Mr. Ryan and the House Republican’s plan calls for more choices, lower costs and greater flexibility while protecting patients with preexisting conditions. “A Better Way” also calls for rejecting the PPACA’s approach of forcing people into Medicaid, which it calls, “… a broken insurance program that has historically failed lower-income families.” They want to streamline the process for getting new procedures and drugs into the mainstream faster than the 14-year time period it currently takes. They also dance around the unsustainability of Medicare with some broadly-worded statements unencumbered by a great deal of specificity, calling for protecting the program for today’s seniors and strengthening it for future generations. One presumes that some portion of the privatization argument will appear as details emerge — a suggestion that lights up most democrats brighter than the White House Christmas tree.