Sunday, October 1, 2017

When we have socialized medicine, you can thank Rand Paul

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Senator Rand Paul
The Graham-Cassidy health-care bill is the last chance to replace Obamacare this year and probably the last chance ever. Several things make that so.  Graham-Cassidy can be passed under budget reconciliation and it will take only 50 votes to pass but after September 30th that option will no longer be available until this time next year.  There are a couple other reasons why the time is now or never to replace Obamacare. One, if not replaced now it will become more entrenched. People do not like change, even change for the better. Also, it has become an accepted value among most people that those with preexisting conditions should not be denied coverage. The longer Obmacare is around the more people are going to be hesitant to support anything that may even possibly appear to threaten that precept.

The other reason is that Republicans will probably be weaker in the future.  If Republicans do not replace Obamacare, then many Republicans are going to be disgusted at Republicans for not doing what they promised they would do and may just sit out the next couple elections or they may vote but not otherwise engage in working in a candidate's campaign or contributing money.  On the other hand, Democrats are going to be motivated and energized to defeat Republicans and protect Obamacare.

But Obamacare is imploding, some will say, and after it implodes we can then repeal it.  I wouldn't bet on it. Certainly, Obamacare has problems. Premiums are skyrocketing and many places in the county only have one company to choose from when shopping for health insurance.  Many people have insurance but not healthcare.  Deductibles are so high that many people cannot afford to use their insurance.

Dissatisfaction with Obamacare will grow over time, but I don't think that will necessarily bode well for those of us who want to see market-oriented reform. While there are Republican proposals that could improve healthcare, Republicans have not articulated them very well and Republicans have not even advocated what it would take to have a real market for health insurance.  To have a real market in health insurance, the premium deduction needs to shift from the employer to the individual. Most people are content with employer-provided insurance, so instead of real reform, Republicans offer tweaking the pre-Obamacare status quo rather than a real alternative. When Obamacare continues to fail, instead of market-oriented reform, I think we will see a move toward a complete government take over. Socialized medicine, single-payer, or "medicare for all" is in our future unless we steer policy in a different direction.

While Graham-Cassidy is not perfect and keeps in place many of the Obamacare taxes it is an improvement.  While I never did fully understand "skinny repeal," I can understand Graham-Cassidy. It is Federalism.  It would replace the top-down, one-sized-fits-all Washington approach to an approach that allows states to experiment and innovate. Sure, it would still be a government program but it would send the money back to the states and allow states to seek waivers to experiment to design their own programs, while ensuring that preexisting conditions continue to be covered. 

It would do away with the individual and employer mandates. It would end the medical-devises tax and it would also slow the rate of growth of Medicare. It would allow states to opt out of Obamacare’s “essential health benefits.” If a state wanted to allow insurance companies to offer policies that did not include prenatal care and child birth coverage, states could do so. Some women who plan on having no more children or who can't have children or some men may not want to pay for a policy that includes prenatal care. Some teetotalers may not want to pay extra for a policy that offers alcohol treatment benefits.

The Republicans look like they are one vote short of having enough votes to pass Graham-Cassidy. One "no" vote is liberal Susan Collins and another is Rand Paul.  I really didn't expect to get Collins' vote, but am disappointing in Paul.  If Graham-Cassidy passes, in some liberal states, state action may impose an individual mandate and an employer mandate and add to the federal subsidy for premium support. California might even want to mandate that polices cover gender reassignment treatment. Some states will have a health care system more liberal than Obamacare while other states may experiment with more market-oriented reforms. In any event the push for change will be at the state level.  If Graham-Cassidy does not pass, the forces favoring "medicare for all" will focus on a national policy change. The public pressure will be for more government; not less.

I know Rand Paul is a principled person, but I don't think a principled person has to reject the good because it is not the perfect.  I think a principled person can ask the question, does this move in the direction I want to go or further away from where I want to go.  A principle person can vote for the imperfect because it is better than what we have now. If Graham-Cassidy does not pass, I think we have socialized medicine, single-payer, in our future. In the future, when Medicare-for-all has become the law of the land, those who favor it can thank Rand Paul.


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