The Two Certainties of Health Care Reform
As Iowans prepared to caucus this week, a battle royal was playing out in each political party. But while Republicans argued over Donald Trump's conservative credentials and Ted Cruz's temperament, Democrats were having a heated debate over actual public policy. At its heart is the future of health care reform in the United States and which alternative--the "evolutionary" incrementalism of the "pragmatic" Hillary Clinton or the single-payer "revolution" of the "idealistic" Bernie Sanders--offers the best path forward both on the merits and on the politics. And as the Iowa vote approaches, the "wonk wars" among academics, analysts and pundits has produced a surprising amount of ill-will between the rival camps.
In response, I have this simple plea to all those of good faith, regardless of the candidate they support: Keep your eyes on the prize.
Six years after the passage of the Affordable Care Act, that prize remains health care that is universal, continuous and more affordable. Despite the indisputable success of Obamacare in reducing the ranks of the uninsured below 10 percent, roughly 29 million people (including undocumented immigrants) still lack coverage. "Universal" means all United States citizens and (at least) all documented immigrants should have insurance. And that insurance should be continuous, with coverage available without interruption even as one's family situation, employment status, income level and age change. Though necessary, these goals are not sufficient. At over 17 percent of the entire U.S. economy, health care must become more affordable for both America and Americans.
Remember that six years after then-Senate Minority Leader Mitch McConnell (R-KY) declared, "I think the slogan will be 'repeal and replace,' 'repeal and replace,'" it is certain that the still TBD Republican alternative will swell the ranks of the uninsured and put the cost of coverage beyond the grasp of millions more. Remember, too, that eight years ago then-Senator Barack Obama opposed the individual insurance mandate and endorsed a single-payer solution as his preferred strategy if he was starting over from scratch. And in 2016 as in the hotly contested 2008 Democratic primaries, there is little reason to think that Senator Sanders and Secretary Clinton won't come together to support their party's presidential nominee and his or her health care program.
But there's also every reason to believe that the health care plans of the next Democratic President will change from their current incarnations. As the experience of the United States and every major industrialized nation around the world shows, there are two certainties of health care reform. First, "fixing the system" isn't a milestone, but a continuous, never-ending process. Second, that process inevitably requires rate-setting. That is, regardless of who pays insurers, hospitals, physicians, clinics and drug companies, in one way or another the government will determine how much.
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