How the Republican Healthcare Mess Makes Sense

Edit: As of Friday afternoon, Sens. McCain (hard no) and Collins (somewhere shy of hard no) have announced opposition, stalling the measure. Let’s hope it stays that way, and that both parties can work on a real plan to improve the healthcare system.

The blade is not yet to the throat, nor the gun to the temple, but by next Friday (or maybe Saturday) America may be in the middle of its biggest hostage crisis of the modern age. The Republicans, in a greedlust for victory on healthcare, are sneaking up behind the country, ready to strike.

The bill, a stinker in a long line of stinkers, will be not a millstone around the GOP’s neck, but a tombstone at its feet, if it ever activates. But that’s not what it’s meant to be at all. This timebomb is DACA 2.0: meant to bend Democrats to the Republicans’ will. Under the president’s DACA order, the hostages are the dreamers. Under Graham-Cassidy, the hostages are the millions who will lose coverage obtained under the ACA.

The notion that the American people are subject to political violence is hardly new or surprising, but it is a heartless and despicable fact. The Republicans want massive wealthcare, but they also want to undo all the things in the ACA they cannot touch under reconciliation rules. This is not serious legislation at all, by any measure. It has not benefited from study or debate, or even from a full CBO score. Governors oppose it, all the medical associations and nonpartisan nonprofits say no.

The only thing that’s left is a hostage play. For the low, low price of 50 votes, the Senate Republicans can shove this mess back to the House, where if the Republicans there can decide to wax their mustaches, they will hold the threat of death over enough Americans that the Democrats will have to cave in. That will, they believe, let them pass a 60-vote bill in the Senate, which will be less insane than Graham-Cassidy, will let them do a victory lap for repealing Obamacare, and will still let them shove a bunch of money in the rich peoples’ pockets.

This sort of abuse is irredeemable. There are millions of people who are stressed and anxious, as hostages to the GOP. This is nothing short of protection racketeering by a major political party on behalf of the wealthy. This is organized crime.

And sadly, that’s the only way this mess of a bill makes sense. All civic-minded Republicans should reject any attempt to hold their countrymen as hostages for legislative ends. A vote for Graham-Cassidy is a vote for tyranny.

Healthcare is Jars of Jellybeans

Insurance functions on risk pools. Think of this as the old jar of jellybeans, where you guess how many of each type are in there. In this case, each person pays to put their jellybean in a jar. There are all kinds of jellybeans, and insurers pay the sum of what’s in each jar, using the money people paid to add their own jellybeans. You want a nice mix of lots of low-cost jellybeans and fewer expensive ones, so that your total doesn’t cost too much.

The individual mandate required people with low-cost beans to add them to the jars. But the Republicans want to do away with that provision, because they believe people should be free not to add their jellybeans if they don’t want to. Fine. But without the mandate, there has to be some other way to balance the mix of jellybeans, if the system is going to work. The Republicans haven’t offered a good solution there.

The main pre-ACA way to deal with the known expensive jellybeans was to set aside jars just for them. The government would subsidize that jar, trying to keep the main jar cheaper. But the government would underfund the high-risk pools, meaning not everybody could put their beans in the jar.

The ACA tried to move the pre-existing jellybeans into the main jar by balancing them with young, healthy jellybeans. Again, the jellybean jar is the main thing to think about when you think about insurance, but the Republicans seem to not know about it. Their plans do not reflect an understanding of this jar and jellybean system.

Under Medicaid, poor peoples’ jellybeans are put in the Medicaid jar, which is cost-shared between states and the federal government. As most poor people are still healthy, and only a small amount are expensive, it works out pretty well even though it’s all paid through government spending.

The ACA expanded that jar in most states, with the federal government paying the overwhelming difference, but some states decided to keep the old jar, meaning there is a gap between jars, with those peoples’ beans just sitting on the counter, not getting covered.


Healthcare is not as complicated as the president claims. It’s only complicated when you deny the essential model of healthcare, when you pretend it’s not jars of jellybeans. When you recognize it is, and you are honest and willing to do what’s needed to make the system work, it becomes a hell of a lot simpler. The Republican reluctance here is all about explicitly not wanting to fix the ACA or do anything that actually works. That’s sad. Maybe they should get them some jars and jellybeans and let the Democrats show them how it works.

Why Don’t Republicans Want the Last Word on Healthcare?

The Democrats took their crack at major reform with the ACA, and since January the Republicans have been seeking to answer it (after their long chants of “Repeal and replace”). But the answers they have produced so far cannot and will not be the final say on the matter. They have to know that. The question is why?

The simplest answer is that they cannot come together on a reply. Their coalition is too broad and divided to give the answer that would be coherent, so they are stuck with simply saying “No” to the Democrats. Rather than admitting that the country needs universal coverage and figuring out how to spread the cost across the concerns, they are stuck simply reducing what the Democrats did.

Those concerns:

  1. Providers’ profits
  2. Taxes of the rich
  3. Taxes of the non-rich
  4. Coverage for the vulnerable (elderly, poor, disabled, etc.)
  5. Insurers’ profits

The Democrats spoke with the ACA, saying: “We will limit insurer profits, increase some taxes on the wealthy, and provide coverage for the vulnerable.” It was a cohesive statement.

But the Republicans are currently saying something like: “We will increase insurers profits, reduce some taxes on the wealthy, and reduce coverage for the vulnerable.” They’re just gainsaying. This is not an argument. It’s mere contradiction. Someone call up Monty Python.

The Republicans have to know that Democrats, next time, will not just repeat their previous statement when they enact healthcare reform. They will probably say, instead: “We will grandfather existing plans, but everybody else goes to a single-payer system paid for by taxes and with costs controlled by negotiating with providers.”

What will the Republicans say to that? “Socialized medicine?” When people will still pay at least part of their premiums, a la Medicare? When the CBO will say that it increases coverage and decreases costs?

This is the Republicans’ best shot at answering the Democrats, but their answer is weak. They may pass it anyway, but it will not be the last word, and they know it.

When an Experiment is Unneeded

The Republican-championed laboratories of democracy, the states, could be used to figure out what’s needed for healthcare in the 21st century. Let the states tinker, find out what works, and then we’ll see it spread.

But those experiments are not needed. We have scores of experiments conducted all over the world. We have all these examples of healthy healthcare in all these other countries. We just don’t have the political will to enact the sensible and sane in the USA.

Now, in Europe each state has its own healthcare system, and the US might still divide a universal system into per-state systems. But the Europeans also have the EHIC system, which allows for dependable treatment when traveling (both unplanned care and for chronic treatment).

The US might still do things different than Europe and the 58 countries with universal care. But the idea that we can’t figure out a problem that 58 other countries have? The amount of denial required to reach that conclusion could only be described as gross negligence.

We don’t need to experiment with allowing states to ignore real insurance in favor of slimmed-down plans that will result in financial burdens on the infirm. We don’t need new work requirements that undermine the definition of universal. We might make some minor use of high-risk pools, but we know the basic shapes that universal coverage come in.

It is high time that any party that seeks national recognition in the US would have a plan for universal coverage. That is a low bar for 2018. The Democrats currently seek a single-payer medicare-for-all style system. If the Republicans do not answer with a 50-states-plus-DC alternative, it will only be a matter of time before CMS is charged with overseeing healthcare across this nation.

We don’t need an experiment. The time where an AHCA or a BCRA might have reflected something the US would do is gone. The cardboard reads “Universal Healthcare or Bust!”

Trade the Rich Their Taxes for Healthcare

Given the amount of control the wealthy have over the state and federal governments, this might be the best market-driven solution to healthcare. The basic outline is that the rich will pay less in taxes (limited to the portion paying for health-related services) as healthcare costs decrease and coverage levels increase. Since they care enough about taxes to make the Republican Party try to pass these bloodthirsty bills (AHCA and BCRA), we should let the rich take control over their own tax destiny.

Now, it’s a little more complicated than described, because there are more rich people in blue states that already make a bigger effort to increase coverage and decrease costs than many red states do. So the mechanism can’t be “if you live in a state that does better, you pay less tax.” That would also not work due to venue shopping, where the rich would just establish residency in states where they would pay less federal tax (some may already do this, if they can deduct state tax from federal and federal from state; but that depends on whether they can control which state their income comes from).

But the basic outline is there. And it could very well be bipartisan if the lever moves both ways. That is, if failure to diminish costs and increase coverage means they pay more tax, the Democrats might be able to deal with a bit of deregulation and help pass it.

Other sticking points would be that there would have to be a fairly rigid definition of coverage (something the Republicans seek to undo with their evil pair of bills), and there would have to be other broad strokes about existing conditions and bans on lifetime and annual maxima. But if the rich hate paying tax that much, they should be drooling at the chance.

Given we pay much more per capita and we don’t even have universal coverage, there should be a lot of cost savings available that the rich can tap to reduce their tax burden. They can buy all the hospitals and streamline them. They can focus on prevention and interventions for patients with high-cost conditions. They can buy the pharmaceutical companies and slash back the price hikes we’ve seen in recent years. Invest heavily in automation.

But one way or another, this country needs affordable care for everybody. If the rich want to get lower taxes in the bargain, I suggest that Congress lets them pull all of us up by their bootstraps.