Look, let’s make it simple.
Obamacare can’t be repealed because the pro-repeal forces don’t have the votes. And if 51 votes in the Senate would do the job, they STILL don’t have the votes.
The two most popular parts of PPACA - pre-existing condition coverage and coverage as a child to age 26 - are untouchable. Expanded Medicaid (without tax increases) is almost as popular. Once you concede you will sell someone fire insurance after their house burns down, you will need a funding mechanism.
So, if the House Republicans have 218 votes for “clean repeal” (I doubt they do), but they keep pre-existing conditions and 25-year old children (because they must) then the economic death spiral leading to nationalization will worsen. But even at that, I doubt there are 30 votes in the Senate for a clean repeal.
To move forward, someone who is profiting from the status quo has to get it in the neck - and I think, after the political process plays out, the Ryan bill fails and Trump’s popularity falls as a result, it is the insurance companies that will be walking the plank.
Medical and hospital care paid for by other people’s money, however collected and however paid out, is fundamentally a political issue. As long as the government takes from you and gives to me to pay my bills, you will want a say in how the money is spent.
Medicare and Medicaid both, in different ways, promised to pay without limit for all medical and hospital services for people covered by them that could reasonably be expected to produce a benefit. Paying without limit with other people’s money is a nice idea, but, as we see, in practice it is unsustainable.
One way or another (presuming our form of government survives), the state must be able to produce a budget for what it will spend on health services. Under the assumptions that govern Medicare, Medicaid, Obamacare, the refugee programs, and others, this is impossible.
Something has to give. I agree with (and pray daily for the survival of) some free market aspects in health care, but the only way this is going to happen is with a national single payer universal basic coverage scheme with a private option.
Obamacare will not survive. Romney-Ryan care can’t pass. Full-on user pays will close most hospitals and practices within a few months.
I believe Trump will propose a single-payer scheme after Ryancare collapses. I hope he sees the wisdom of a private option. But, one way or another, single-payer will be a reality.
Your analysis of the conundrums associated with the politics of replacing Obama care, even of repealing Obama care, are salient. Many of them have been anticipated by us and it has caused me to advise this administration and Republicans to be very careful about embracing this tar baby.
In fact, I advise they let Obama care implode and only then come in and clean up the mess to avoid the very problems they face today. Trump has brought much of this on himself when he made promises that were simply mathematically impossible but he was correct at least once when he said that the Republicans were rescuing the Democrats by taking over and reforming Obama care. It was a foolish thing to do probably occasioned by overheated campaign rhetoric.
As it looks now, by Trump and the Republican establishment trying to be all things to all people means that conservatives and moderates will feel betrayed and Democrats will have escaped the tar baby stigma of their own making.
We will be lucky to emerge from this with a conservative coalition intact and some sort of health insurance law that kicks the reckoning down the road a generation.
