For all the complexity of health care, efforts to improve it really comes down to one dividing line: Either you think Washington’s central planners know best, or you don’t.
The past several decades have been one long exercise in yielding more and more authority to a small group of decision makers, despite scant evidence this approach has been working and much evidence that it hasn’t. The high-water mark for this kind of thinking is the Affordable Care Act.
At least, so far it is. Now there’s a move under way to scuttle even the small opening Georgia and other states see as their only chance to bring some sanity back to their battered insurance markets for individuals and small businesses.
To understand what’s going on, first recall the hubris of the ACA’s authors. They thought they could wrest regulatory authority over insurance from the states, mandate a slew of coverages, crimp the ability of insurers to differentiate the prices of their products for riskier or more frequent users of health care, subsidize it heavily for a segment of the population — and end up with something besides a market with less competition and higher prices, one rejected by many Americans even though they faced a tax penalty for doing so.
Predicting these problems required no prescience on the part of ACA critics, just an understanding of how markets actually work.
Despite all that, the law did include a provision all but acknowledging the authors might not have it all right. Section 1332 of the ACA allows states to propose innovative ways to reform their health-insurance markets. The states do this by applying for waivers, as the General Assembly this year authorized Gov. Brian Kemp to do.
The problem was the initial guidance for implementing this flexibility, issued by the Obama administration in 2015, allowed no real flexibility. It was like bringing someone a broken-down car, and telling them they could use as much paint and duct tape to fix it as they wanted — as long as they didn’t actually work on the engine.
Late last year, the Trump administration changed course. It offered states four explicit ways to innovate in their markets, and encouraged them to find others. Certain legal guardrails remain in place, meaning the states still have to work within the ACA’s parameters. But each of the four ways gives states a real chance to fix some of what’s wrong with their markets.
Naturally, this horrifies those who pretend the broken-down car is just fine, and don’t want anyone touching the engine.
This past week, House Democrats approved a bill that would go back to the paint-and-duct tape method of improvement. The bill claims to protect patients with pre-existing conditions, but that’s nonsense. The ACA specifically prohibits states from waiving those protections.
So what’s really going on here?
The bill refers to patients with pre-existing conditions because Democrats know Americans overwhelmingly support those protections. In fact, only in its title does the bill even mention pre-existing conditions. That’s because it would ban all of the Trump administration’s guidance on these innovative reforms, even things like allowing people to collect their ACA subsidies in accounts to use for healthcare expenses beyond insurance premiums.
Fortunately, the bill appears to be dead on arrival in the Senate. At the root, however, this effort is about ensuring no state gets a chance to enact reforms that prove a more market-oriented approach can work better for patients, providers and taxpayers.
After years of arguing against repealing and replacing the ACA, many Democrats are now ready to do essentially that. Only, instead of getting away from a Washington-centric approach, they would go all-in on it with a single-payer plan.
It won’t work. We’ll see a further reduction in choices and competition. We’ll see a further increase in prices — and that may come in the form of higher taxes, more debt and longer wait times.
This engine needs a total overhaul, and not by Washington.