In healthcare: The debate is dead. Long live the debate.
U.S. politics has been roiled for over a decade by disputes over the Affordable Care Act (ACA, or “Obamacare”). However, three recent developments really mean that the big debate is effectively over. The disputants are haggling over marginal details, not battling over great principles.
However, this change offers the opportunity to switch to a different debate. To worry less about health insurance and more about the delivery of care.
Let’s begin with the three big developments:
First, in oral arguments over the case of California versus Texas, Chief Justice John Roberts and Justice Brett Kavanaugh (and perhaps Justice Sam Alito) strongly telegraphed that they wouldn’t strike down the ACA even if they find that the law’s hollowed-out individual mandate is unconstitutional.
Second, the November elections likely ended chances for Medicare for All (M4A), where the federal government would pay for all healthcare. Sen. Bernie Sanders’ M4A bill had its day during the Democratic primary debates. President-elect Biden and other candidates urged less sweeping approaches, like a “public option.”
And third, Republicans have essentially endorsed the ACA’s central organizing principle — guaranteed insurance coverage for those with pre-existing medical conditions.
Upon signing a presidential executive order in September, President Trump declared: “The historic action I’m taking today includes the first-ever executive order to affirm it is the official policy of the United States government to protect patients with pre-existing conditions, so we’re making that official.”
But, the ACA had already done that, and the GOP had focused its messaging on coverage for those with pre-existing conditions as early as 2017.
Whether or not to guarantee coverage for those with pre-existing conditions was the central divide in the 2010 ACA debate. The ACA combined guaranteed issue (insurers must sell policies to anyone, regardless of their health status) and modified community rating (insurers can’t charge higher premiums to those with costly illnesses).
In 2010, Republicans opposed the ACA’s guaranteed issue-plus-community rating out of fear that such a policy would destabilize existing insurance markets (as had happened in several states).
But covering those with pre-existing conditions is now Republican mantra, and their differences with the Democrats are more about how to accomplish that rather than whether to do so.
The end of the old debate offers us a powerful opportunity to refocus on this more productive, less partisan set of questions.
Robert Graboyes is a senior research fellow with the Mercatus Center at George Mason University, where he focuses on technological innovation in healthcare. He is the author of “Fortress and Frontier in American Health Care” and has taught health economics at five universities. He wrote this for InsideSources.com.
