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Policymakers should eat their ACA change supper

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Some of the new Republican proposals for changing or replacing the Affordable Care Act seem sillier than the earlier proposals.

Related: Conservatives object to Obamacare replacement proposal tax credits

Backers of some earlier efforts to repeal or replace the ACA had a sobering but credibly grim message: That doing without health coverage guarantees, or generous health care access guarantees, is the price we might have to pay to free ourselves from black holes of expensive, time-consuming, initiative-suffocating red tape.

Backers of the no-guarantee, or low-guarantee, approach to ACA reform would say that broad, generous guarantees often backfire. They can become so burdensome that they end up making the health care access situation worse rather than better.

These days, on the other hand, creators of some of the new ACA replacer proposals start by proposing that we should keep the nice things in the ACA. They start by declaring that we should keep the ban on health insurers looking at people’s health problems when deciding whether to sell people coverage, or when setting the price for coverage. Then they throw in a few paragraphs about improving health savings accounts and fighting health care fraud, and, bam, the proposal is done.

On the one hand: Anyone with a heart knows that we have to provide some minimum level of health care for people who have no way to pay for it. Supporters of a genuinely pure free-market approach to health finance will say that eliminating government and managed care red tape would free so much of doctors’ and hospitals’ resources that they could easily provide all of the necessary charity care.

But, on the other hand, the reason we have so much managed care and government red tape to start with is because, in this world, with the medical technology we have now, providing an affordable, sustainable, stable, simple health finance system that most people like, including sick people, is impossible.

A few decades from now, maybe we’ll have vaccines against cancer and heart disease, and three-D printers that can make free androids that can provide any care we still need. If a Death Star comes and blasts us, our free medical android surgeons will put us back together, then make us a nice dinner.

Today, however, there are only three ways to operate a large health finance system:

        1. Raise a lot of money, by charging health plan members high premiums, imposing high taxes on ordinary people, and, or, imposing high taxes on companies. (Which, of course, are owned by people.)
        2. Use cruel free-market forces or complicated rules and bureaucracies to manage how much care people get.
        3. Create a health finance system cocktail made up of raising a lot of money, using cruel free-market forces, and, or, complicated care-management programs and rules.

The cheaper the system is, the less care it can provide per person. The less care the system can provide per person, the more some player, or free-market force, has to limit use of care.

Health care reporters in every system always have an easy time writing a story about how the cost of the system is too high, some group of care providers is earning too little, or some group of patients is getting too little care. The instant you fix one thread in the cost-pay-care braid, the other two will fray.

Another way to put this is, we’re all like 5-year-olds at a formal restaurant. We know that the restaurant serves a great chocolate marshmallow bunny cake. Our parents expect us to eat our chicken fingers, which taste like sawdust, before we can eat the bunny cake. When the waiter asks us what we want, we skip right to ordering the bunny cake, and we have a tantrum when our parents insist on ordering the sawdust fingers.

In this case, however, it’s not our rotten parents making us eat the sawdust, but the cost-pay-care health finance system braid. We can eat the sawdust of paying higher premiums, or higher taxes. We can eat the sawdust of having to deal with annoying red tape and awful bureaucracies. Or we can eat the sawdust of seeing desperate, worthy people going without care. But, somewhere along the way, if we want the bunny cake of guaranteed-issue major medical coverage, we’re going to have to eat sawdust.

If would-be ACA repairers, repealers, replacers, or, obviously, defenders, pretend that we can have the bunny cake without the sawdust, they’re just trying to hide the sawdust.


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