Now the new people in Washington get to take a turn at trying to balance mercy and math. (Photo: Thinkstock)

I write this five weeks before Donald Trump is set to take office as president of the United States. About all I feel confident about predicting is that the universe will contain molecules.

If Donald Trump persuaded all of the Democrats in Congress to vote to repeal and replace the Affordable Care Act during his first month in office, that would make me nod sagely and read a few ACA repeal articles.

If Trump simply kept most of the ACA in place as is, tweaked the premium tax credit system and expanded the health savings account program, that would make my head spin, but slowly. Health reform is hard.

Trump is a man who’s used to cutting through complicated problems, and many of his early cabinet secretary picks are people who are used to finding clear, straightforward paths through complicated problems.

Related: Why Trump’s defense pick could be a health policy player

A pick for Defense secretary, James Mattis, is a retired Marine Corps general who has said that he has never been at a loss for ideas because he has read widely and learned from the experience of the people who have come before him.

On the one hand, that kind of respect for the idea of reading up could come in handy for anyone who hopes to replace the Affordable Care Act commercial health insurance programs with something simpler and cheaper, rather than replacing one snarl of regulatory spaghetti with a new snarl of regulatory spaghetti. Someone who respects reading might scour the libraries of the nation for old bound print volumes of National Underwriter Life & Health. Cabinet secretaries who peruse those will learn of the sad fate of health reformers in states such as Kentucky and Washington, which eliminated individual medical underwriting and chased most of the carriers away.

Related: AHIP looks at how state laws impact insurance market

On the other hand, cabinet secretaries who are used to finding simple, straightforward solutions to problems might have a hard time dealing with health insurance. People who are used to wandering around wondering where they left their phone might be more comfortable with that foggy universe.

Some free-market purists do have a simple solution: They say that people who can pay for care, or persuade others to pay for it voluntarily, should get it, and that no other free adult civilians should.

No one with a softer heart than that has a simple solution for health care costs.

Advocates of pure government-run systems think they do, but there are only two ways to keep a true single-payer system going: With large, increasing cash subsidies, to make up for the patients’ growing, poorly restrained demands for care, or with some combination of publicity to make the patients love the system and police to hold them inside it. If a single-payer system with normal levels of financing faces competition, the richer, easier-to-treat patients flee to a faster, more flexible private system. Wealth flight will eventually destabilize the public system.

Every system with a lesser degree of government involvement will face some degree of the same problems, with government-enhanced access to insurance increasing everyone’s use of care, and government efforts to help sick people get a good deal on insurance encouraging the healthier people to leave and destroy the kinder market.

Few of us have the stomach to let nice, easy-to-save people die on the sidewalk because of lack of antibiotics, or appendectomies. Because of that, we’re doomed to participate in the same serious health financing commissions people have been organizing for the past few centuries, and to create the same kind of regulatory snarls.

Once some Affordable Care Act critics say something like, “We really should require insurers to let parents keep their children on their coverage up to age 26,” or, “We should give all 18-year-olds a one-time chance to buy health coverage with no worries about their health status,” they’re already starting down a path toward creating an “alternative” that might look more like the Affordable Care Act than they’d like to think.

Allison Bell is the health channel editor for LifeHealthPro.com.

Related:

Self-funding and the nonmarketplace

Republicans’ new ACA replacer, dissected

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