When I cast my Senate vote for the Affordable Care Act in 2009, I had a lot of mixed feelings. The bill certainly didn’t do everything I had hoped for, and I knew parts of it would have to be revised by future Congresses. But I was sure that the health-care system we had was broken, and the ACA went at least part of the way toward fixing it.
I knew we spent far more per capita on health care than any country in the world, but the World Health Report ranked our system as 37th in overall effectiveness. I knew that practically every president since Harry Truman had tried and failed to pass health-care reform. I believed that if we didn’t pass the ACA in 2009, no future president would find it politically feasible to revisit the issue, and exploding costs would ultimately devastate federal and state budgets as our entire health-care system began to crumble.
I haven’t changed my mind about the ACA in the years since. But until very recently, there has been little or no talk about improving the law. Instead, we have lived through nearly five years of the most sustained attack on one law I have seen in my lifetime. There has been no room in the debate for talk about changes. One side insisted - to the point of over 50 votes in the House of Representatives - on total repeal of what has come to be known as Obamacare. The other side, frankly, had its hands full trying to defend the act, and was reluctant to give the repeal-no-matter-what side any additional ammunition by talking about revisions.
That just may be changing. An amendment to the ACA proposed by Rep. John Carney, D-Del., actually passed the House last week. And I was struck by a recent town hall meeting exchange between Rep. Dennis Ross, R-Fla., and an angry constituent, who asked him “why do you think it is a good idea to deny seniors on Part D to make them pay more, about $4,000 more for medicine, and people with pre-existing conditions get denied insurance, have 25-year-olds have a harder time getting insurance because they can’t get on their parents’ plans.” The congressman’s answer was, I think, very different from what it would have been a few months ago, given that he had voted for all of the repeal motions in the House. “I don’t,” he said. “I think one of the most unfortunate things my party did the last three years was not offer an alternative to health care.”
That exchange happened after the announcement that 8.5 million people had signed up for individual Obamacare insurance. But it also came after at least a year of repeated promises by House and Senate Republican leaders that they would “soon” announce a Republican alternative.
We are still waiting, and I’d like briefly to explain why. The reason is simple: if you are going to come up with a health-care system that relies on the private insurance market, and if you are going to make sure people with pre-existing conditions cannot be denied insurance, it is next to impossible to come up with an alternative that doesn’t look something like (sorry, my Republican friends) Obamacare.
Why not just take out the admittedly unpopular (no surprise, given the hundreds of millions spent to attack it) individual mandate? Think what would then happen if insurers still couldn’t deny insurance to people with pre-existing conditions. There would be little reason for a healthy person to buy insurance. Instead, most would wait until they got sick. With only unhealthy people in the insurance risk pool, rates would skyrocket and the whole system would collapse.
That’s why the conservative Heritage Foundation came up with the idea of the individual mandate to make Massachusetts’ Gov. Mitt Romney’s health care program work. As he said in 2006, “the individual mandate, that is essential for bringing health care costs down for everyone and getting everyone the health insurance they need.”
Gov. Romney point was valid, then and now. To make any health insurance plan work, the broadest possible risk pool, including healthy and less healthy people, young and old, is essential. That’s the real Republican dilemma about an alternative to Obamacare. And that’s why there is reason to hope that we will soon begin the conversation we should have been having all along - how to make it better.
Ted Kaufman is a former U.S. senator from Delaware, and writes regularly for the News Journal. Contact Ted and read more of his work at tedkaufman.com.